Anal Fistulotomy

CPT 46270 · 4.8 wRVU · 90-day global
CPT46270
wRVU4.8
Global90-day
ApproachOpen
ComplexityModerate
Add-on / Variant CPTs
  • 46280 wRVU: 6.23 — Complex or horseshoe fistula
  • 46285 wRVU: 5.28 — Second stage, horseshoe fistula
Preoperative Diagnosis:

Anal fistula-in-ano

Postoperative Diagnosis:

Same

Procedure Performed:

Examination under anesthesia, fistulotomy

Attending Surgeon:

[Attending name], MD

First Assistant:

[Resident/Fellow/PA name]

Anesthesia:

General or spinal

Indications:

Patient presents with recurrent perianal abscess and fistula-in-ano. Preoperative evaluation confirmed low intersphincteric or transsphincteric tract with acceptable sphincter involvement. Adequate anorectal continence. Procedure discussed including risks of incontinence, recurrence, and wound healing.

Findings:

Examination under anesthesia revealed a [low intersphincteric / transsphincteric / superficial] fistula-in-ano at the [clock position] position. Internal opening identified at the dentate line at the [clock] position. External opening located [X] cm from the anal verge. Tract probed without evidence of secondary extensions. [Goodsall's rule applied / direct probe passed]. Sphincter involvement estimated at [<30%] of external sphincter. (Note: involvement >30% is a relative contraindication to fistulotomy; consider seton or sphincter-sparing approach.)

Description of Procedure:

The patient was taken to the operating room, positioned in [prone jackknife / lithotomy] position, and prepped and draped in sterile fashion. A self-retaining retractor was placed for exposure. Examination under anesthesia was performed.

The external opening was identified [X] cm from the anal verge at [clock] position. A malleable probe was gently introduced through the external opening and advanced to exit through the internal opening at the dentate line at the [clock] position, confirming a [low / simple] fistula tract with minimal sphincter involvement.

The overlying tissue was divided with electrocautery along the probe from external to internal opening, laying open the fistula tract. The tract was curetted of all granulation tissue. The wound edges were marsupialized using absorbable suture (2-0 Vicryl) to reduce dead space and facilitate healing.

Hemostasis was confirmed. [Packing was placed / no packing placed — current evidence does not support routine packing and it may increase pain without benefit (Pearce et al., Tozer et al.).] The patient tolerated the procedure well.

Complications:

None

Specimens:

Fistula tract curettings [sent to pathology if Crohn's disease, malignancy, or atypical features suspected / not sent for routine cryptoglandular fistula]

Estimated Blood Loss:

Minimal

Drains:

None / Wound packed with Vaseline gauze

Disposition:

Patient was taken to PACU in stable condition. Discharged same day.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: Anal fistula-in-ano
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Examination under anesthesia, anal fistulotomy
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General / spinal

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with recurrent perianal abscess and fistula-in-ano. Preoperative evaluation confirmed low intersphincteric/transsphincteric tract with acceptable sphincter involvement. Risks including incontinence, recurrence, and impaired wound healing were discussed. Informed consent obtained.

FINDINGS: EUA revealed a [low intersphincteric / transsphincteric / superficial] fistula at the *** o'clock position. Internal opening identified at dentate line at *** o'clock. External opening *** cm from anal verge. No secondary extensions. Sphincter involvement estimated at <30% of external sphincter. (Involvement >30%: seton or sphincter-sparing procedure preferred per ASCRS 2022.)

DESCRIPTION OF PROCEDURE:
The patient was taken to the OR, positioned in prone jackknife position, and prepped in sterile fashion. A self-retaining retractor was placed. EUA was performed. The external opening was identified *** cm from the anal verge. A malleable probe was introduced through the external opening and advanced to exit through the internal opening at the dentate line, confirming a low [intersphincteric / transsphincteric] fistula. The overlying tissue was divided with electrocautery along the probe from external to internal opening, laying open the tract. The tract was curetted of granulation tissue. Wound edges were marsupialized with 2-0 Vicryl to reduce dead space. Hemostasis confirmed. Vaseline gauze packing placed. Patient tolerated the procedure well.

ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Fistula tract curettings to pathology
COMPLICATIONS: None
DRAINS: Wound packed with Vaseline gauze
DISPOSITION: Patient taken to PACU in stable condition. Discharged same day.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Seton placement (high transsphincteric)

When sphincter involvement >30%, place a draining seton rather than divide. ASCRS 2022 guideline uses <30% external sphincter as the threshold for safe fistulotomy. Also consider seton for anterior fistulas in women, prior obstetric sphincter injury, pre-existing incontinence, Crohn's disease, or recurrent fistulas. Document seton material, tension, and plan for staged division.

Lift procedure

For high fistulas: ligation of intersphincteric fistula tract (LIFT). Document intersphincteric space dissection and ligation of tract at internal sphincter.

Video-assisted anal fistula treatment (VAAFT)

Document endoscope visualization, internal opening closure, and obliteration of tract.

Charting Tips
  • Document clock position of internal and external openings precisely
  • State estimated percentage of sphincter muscle divided. This is critical for medicolegal documentation and recurrence risk assessment.
  • In women, the anterior external sphincter is substantially shorter than in men (mean ~1.2 cm vs. ~2.7 cm anteriorly). An anterior fistula that appears to involve less than 30% of the sphincter by probe-to-palpation may functionally divide a much higher proportion of the continence mechanism. Document fistula clock position and patient sex explicitly. Anterior location in women is the highest-risk combination for post-fistulotomy incontinence and should prompt strong consideration of seton or sphincter-sparing approach regardless of apparent depth.
  • Note Goodsall's rule application and any deviation. Goodsall's rule has only moderate predictive accuracy (approximately 50-70% overall, less for anterior fistulas); it guides initial orientation but should not substitute for direct probing under anesthesia. Preoperative MRI is recommended for complex or recurrent fistulas.
  • If seton placed, document material, looseness, and plan for staged removal
  • Document presence/absence of secondary extensions or horseshoe component
Billing Tips
  • Bill 46270 for subcutaneous anal fistulotomy (4.80 wRVU, 90-day global). Use when the fistula tract is entirely subcutaneous with no sphincter involvement.
  • Bill 46275 for intersphincteric fistulotomy (5.28 wRVU) when the tract passes through the internal sphincter only. Bill 46280 for complex fistulotomy (6.23 wRVU) involving trans-sphincteric, suprasphincteric, or extrasphincteric tracts.
  • Code selection depends on the anatomic relationship to the sphincter mechanism. Document the tract location by EUA findings, probe-to-palpation technique, and relationship to the sphincters. This is the single most important billing determinant.
  • Seton placement without fistulotomy uses 46020 (placement of seton, 1.81 wRVU). If seton is placed as a staged first step, document that fistulotomy was deferred. Codes 46270-46280 are used at the definitive fistulotomy stage.
  • 90-day global period: wound packing, office follow-up, and sitz bath instructions are bundled. Advancement flap or LIFT procedure at a separate setting is a new billable procedure.

General coding reference. Verify with your institution’s billing department before submitting claims.

ⓘ General Billing Tips →