Do anal fissures and anal fistulas cause you coding confusion? These two terms sound similar, but refer to different conditions. The treatment of these two conditions is also coded differently. Our article today is dedicated to helping you master the difference between anal fissures and fistulas so you can code the treatment of these conditions confidently.
The information we will cover in this article is very technical (lots of medical terms and anatomy to be familiar with). I’ve included some helpful definitions and links with pictures for those of you who are visual learners. It may take a couple of reads or some additional research (e.g., watching videos) to completely visualize and understand these procedures, but the information presented here should give you a great start.
- An anal fissure is a tear in the lining of the anus or rectum. These tears can occur for a variety of reason, but constipation and passing hard stools are common causes of anal fissures.
- An anal fistula is a tunnel/tract between the anus and the skin around the anus. Again anal fistulas have different causes, but one common cause is an old abscess that did not heal completely. There are many different types of fistulas that are usually named based on their location:
- Intersphincteric: Inter means between and sphincteric refers to the muscles that control the opening and closing of the anus. There are two sphincters in the human body: one internal and one external. An intersphincteric fistula is one whose tract begins in between the internal and external sphincters and exits typically around the opening of the anus.
- Extrasphincteric: Extra means outside or beyond. An extrasphincteric fistula is one whose tract begins in the rectum or sigmoid colon and continues through the levator muscle and ends around the anus. This type of fistula does not involve the sphincters or the space between them, so it is “extra” or “outside” the sphincters.
- Transsphincteric: Trans means across. A transsphincteric fistula is one whose tract begins in the space in between the internal and external sphincters or in the space behind the anus, comes through/across the external sphincter, and exits within a couple of inches of the anal opening.
- Suprasphincteric: Supra means “above.” A suprasphincteric fistula is one which begins in the space between the internal and external sphincters and then passes above them (usually taking a route initially above and then through the puborectal muscle and then through the levator ani muscle to exit within a couple of inches of the anal opening).
- Subcutaneous: This type of fistula sometimes referred to as a “superficial” fistula, is just underneath the surface of the mucosal lining of the rectum in the subcutaneous tissues. It does not involve the sphincters or the inter or suprasphincteric spaces and instead is a more superficial, low-lying fistula.
- Second Stage: This last term, a “second stage” fistula is actually not referencing a location but a set of conditions under which a fistula is treated. Sometimes with extensive fistulas that involve the sphincters, the surgeon may have to address the problem in two separate operations by opening up/excising part of the fistula in the first operation (first stage) and then opening up/excising the rest of the fistula tract after some healing has occurred in the second operation (second stage).
If you are more of a visual learner, check out these links which depict the different types of fistulas:
- The first link shows you the anatomy of the anus including the internal and external sphincters and the intersphincteric space (the space between the internal and external sphincters) so you can really visualize where these structures and spaces are located: Anatomy of the Anus
- The second link shows you lines along the anatomy of the anus that depicts the different locations of the fistulas defined above: Types of Anal Fistulas
Now that we have some important anatomy and terms under our belts, let’s start talking about how to code treatment of fissures and fistulas.
Step #1: The first step is to determine if the condition requiring surgery is an anal fissure or an anal fistula. This may sound obvious, but I have seen many times that these two conditions were confused for each other, resulting in a wrong CPT code. Hopefully the definitions above help you determine which condition is appropriate.
Step #2: The next step is to determine the type of surgical procedure performed to treat the condition. Here are some possibilities:
- Surgical Excision: The surgeon may “cut out” the fissure or the fistula tract to remove it completely or in part. When treating a fissure in this way, the surgery is called a fissurectomy. When treating an anal fistula in this way, the surgery is called a fistulectomy.
- Surgical Opening: The surgeon may “cut open” the diseased area to allow the area to drain and heal. This typically happens with a fistula but not a fissure so if a term ending in “otomy” is present in the report, that’s a good sign that you are looking at an anal fistula rather than an anal fissure.
- Closure with Glue: As strange as this may sound, there is a special glue that can be used to close more superficial fissures and fistulas in the anus. This glue is called fibrin glue.
- Closure with Flap: The surgeon may create a small flap of tissue from the surrounding tissue that can be rotated over the fissure or fistula to close it.
- Placement of a Seton: A seton is made of cotton or other absorbable tissue and is passed into the opening and left protruding outside it. The goal is for the fistula to heal around the seton. The seton can then be pulled out or may fall out on its own.
- Destruction: Using cautery (heat) or curettage (scraping) to destroy an anal fissure or fistula.
Below are the established CPT codes available for treatment of anal fissures and anal fistulas when performed as the only anorectal surgical procedure during the case.
.Anal Fissure Treatment
Destruction:
- 46940: Curettage or cautery of anal fissure, including dilation of anal sphincter (separate procedure); initial
- 46942: Curettage or cautery of anal fissure, including dilation of anal sphincter (separate procedure); subsequent
As you can see, there are two codes for “destruction” (i.e., cautery or curettage) of an anal fissure. You choose the code based on whether this is the initial treatment or if this is a subsequent treatment of the same fissure.
Excision
- 46200: Fissurectomy including sphincterotomy, when performed
This code is reported when the anal fissure is excised. A sphincterotomy (cutting the sphincter muscle to allow it to relax/stretch) may also be performed. The sphincterotomy is included in CPT 46200 when performed but is not required to code this CPT.
Anal Fistula Treatment
Excision or Opening:
- 46270: Surgical treatment of anal fistula (fistulectomy/fistulotomy); subcutaneous
- 46275: Surgical treatment of anal fistula (fistulectomy/fistulotomy); intersphincteric
- 46280: Surgical treatment of anal fistula (fistulectomy/fistulotomy); transsphincteric, suprasphincteric, extrasphincteric, or multiple, including placement of a seton, when performed
- 46285: Surgical treatment of anal fistula (fistulectomy/fistulotomy); second stage
You will recognize a lot of the terms we have already discussed in these code descriptions.
- The first thing to notice is that all of these codes are for “surgical treatment” of the fistula which is defined as a fistulectomy, a fistulotomy, or both.
- The next thing to notice is that the location of the fistula (subcutaneous, intersphincteric, etc.) helps you choose the appropriate code.
- For CPT 46280, this code includes a seton placement “when performed.” So again, if the surgeon places a seton it is included in 46280, but it is not required in order to report this code. For all other types of fistulas not described in CPT 46280 (e.g., subcutaneous, intersphincteric, etc.), you may report both the code for the fistulectomy/fistulotomy plus code 46020 for placement of a seton when both procedures are performed.
- Also, CPT 46280 can be reported for a fistulectomy/fistulotomy of multiple fistulas regardless of what type of fistula is treated (i.e., if the surgeon treats both a transsphincteric and an intersphincteric fistula which would normally fall under different CPT codes when treated by themselves, they would be treating “multiple” fistulas which would be CPT 46280 alone.
- Finally, CPT 46285 is for a “second stage” procedure to treat any type of anal fistula. Again the second stage procedure would be for cases where the same fistula has already been treated partially in a prior procedure and the patient is brought back for a second procedure to complete surgical treatment of the fistula.
Closure with an Anal Flap:
- 46288: Closure of anal fistula with rectal advancement flap
This code is used to report treatment of any type of anal fistula that is closed/repaired with a rectal advancement flap.
Closure with Glue:
- 46706: Repair of anal fistula with fibrin glue
This code is used to report closure/repair of any type of anal fistula with glue. Notice that this code is in a totally different section of CPT than the rest of our anal fistula codes (467xx rather than 462xx). This code emphasizes the importance of good technique when searching for a CPT code (starting with an index search and then looking at the full description in the CPT manual). This technique ensures you have looked at all of your options and applied the best CPT code to describe the procedure performed. If you went to the 462xx section of CPT alone to start your search, you would miss this code option.
The codes above are for treatment of anal fissures and fistulas by themselves. In our next article we will look at some combination codes that might apply when these conditions are treated along with other conditions of the rectum/anus such as abscesses and hemorrhoids. We will also look at some surgical coding examples to help illustrate how all of these codes might apply to different cases and help you master picking the correct CPT for your particular scenario.