Overlapping Sphincteroplasty
4675046761wRVU: 14.91 — Sphincteroplasty with levator muscle imbrication (Park posterior anal repair) — use instead of 46750 when levatorplasty is performed (14.91 wRVU)46751wRVU: 9.07 — Sphincteroplasty, anal, child — standalone primary code for pediatric patients; not an add-on (9.07 wRVU)
Fecal incontinence, external anal sphincter defect
Same
Overlapping external anal sphincteroplasty
[Attending name], MD
[Resident/Fellow/PA name]
General or spinal
Patient presents with fecal incontinence secondary to [obstetric / traumatic / iatrogenic] external anal sphincter disruption. Preoperative anorectal manometry demonstrated reduced resting/squeeze pressures. Endorectal ultrasound confirmed anterior sphincter defect spanning [X degrees / X clock positions]. Sacral neuromodulation has been discussed and [was not preferred by the patient / was deemed less appropriate given clinical factors including X]. Bowel preparation completed. Risks including recurrence of incontinence (significant long-term deterioration after 5-10 years is well documented), infection, wound breakdown, and dyspareunia discussed with patient.
Patient positioned in prone jackknife position. Examination under anesthesia confirmed anterior disruption of the external anal sphincter. Scar tissue identified within the defect. Internal sphincter [intact / also disrupted]. Puborectalis and levator ani [intact].
The patient was taken to the operating room and placed in [prone jackknife / lithotomy] position following general anesthesia. The perineum was prepped and draped in sterile fashion. A curvilinear incision was made over the anterior perineum, centered over the sphincter defect.
Dissection was carried through subcutaneous tissue, and the external sphincter ends were identified bilaterally. The scar tissue within the defect was [sharply divided in the midline to facilitate mobilization / partially excised]. The sphincter ends were mobilized laterally to allow 1.5-2 cm of tension-free overlap.
The puborectalis and levator ani muscles were plicated in the midline with interrupted 2-0 PDS sutures. The external sphincter was then overlapped in a double-breasted (overlapping) technique using multiple interrupted mattress sutures of 2-0 PDS, achieving approximately [X] cm of overlap without tension.
The wound was irrigated copiously. [A closed-suction drain was placed / No drain placed.] The skin was closed loosely with interrupted absorbable sutures to allow drainage. The patient tolerated the procedure well.
None
None
Minimal
[Closed suction drain placed through separate stab incision / None]
Patient was taken to PACU in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Fecal incontinence, external anal sphincter defect
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Overlapping external anal sphincteroplasty
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General / spinal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with fecal incontinence secondary to [obstetric / traumatic / iatrogenic] external anal sphincter disruption. Preoperative anorectal manometry demonstrated reduced squeeze pressures. Endorectal ultrasound confirmed anterior sphincter defect spanning *** clock positions. Bowel preparation completed. Risks including recurrence of incontinence, infection, and wound breakdown were discussed. Informed consent obtained.
FINDINGS: EUA confirmed anterior disruption of the external anal sphincter from *** to *** o'clock. Scar tissue within defect. Internal sphincter intact. Puborectalis and levator ani intact.
DESCRIPTION OF PROCEDURE:
The patient was placed in [prone jackknife / lithotomy] position following induction. Perineum prepped in sterile fashion. A curvilinear incision was made over the anterior perineum, centered over the sphincter defect. Dissection carried through subcutaneous tissue; external sphincter ends identified bilaterally. The scar tissue within the defect was [divided in the midline / partially excised] to facilitate mobilization. The sphincter ends were mobilized laterally to allow *** cm of tension-free overlap. The puborectalis and levator ani were plicated in the midline with interrupted 2-0 PDS. The external sphincter was then overlapped in a double-breasted (overlapping) technique using multiple interrupted mattress sutures of 2-0 PDS, achieving approximately *** cm overlap. Wound irrigated copiously. [Closed-suction drain placed / No drain.] Skin closed loosely with interrupted absorbable sutures. Patient tolerated the procedure well.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: None
COMPLICATIONS: None
DRAINS: [Closed suction drain / None]
DISPOSITION: Patient taken to PACU in stable condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
With internal sphincter repair
If internal sphincter defect present, plicate separately with fine absorbable suture before external sphincter overlap.
Concurrent levatorplasty
Document midline plication of levator ani and puborectalis prior to sphincter overlap.
Charting Tips
- Document extent of defect in clock positions (e.g., 10 o'clock to 2 o'clock)
- {'Note scar management': 'whether scar was divided in the midline (current standard to allow overlap), partially excised, or preserved. Scar-preservation-as-standard is historical; most contemporary technique divides or mobilizes the scar.'}
- Document achieved overlap distance (target 1.5-2 cm), not just suture count
- Document suture material (2-0 PDS is commonly used; evidence does not clearly favor it over Vicryl, but PDS is widely preferred for its longer tensile retention)
- Note any levatorplasty performed — if so, bill 46761 rather than 46750
- Note patient positioning (prone jackknife or lithotomy; both are acceptable)
- Bowel regimen and follow-up anorectal manometry should be addressed in postoperative plan
- Document discussion of sacral neuromodulation as an alternative, particularly for chronic fecal incontinence — the 2023 ASCRS CPG positions SNS as a first-line surgical option for chronic FI, and notes that sphincteroplasty benefits diminish significantly by 3-5 years. The decision between approaches should be individualized and documented.
Billing Tips
- Bill 46750 for overlapping sphincteroplasty, adult (11.85 wRVU, 90-day global). This is the base sphincteroplasty code for anterior sphincter repair for fecal incontinence following obstetric injury, trauma, or prior anorectal surgery. It does NOT include levatorplasty.
- Bill 46761 for sphincteroplasty with levator muscle imbrication (Park posterior anal repair) (14.91 wRVU, 90-day global). Use this — not 46750 — when levatorplasty is performed as part of the repair.
- Bill 46751 for the pediatric equivalent of sphincteroplasty (9.07 wRVU, 90-day global). This is a standalone primary code for a child patient, not an add-on to 46750. Do not report 46751 alongside 46750.
- Bill 46760 for sphincteroplasty with muscle transplant (e.g., gracilis transposition) (17.01 wRVU, 90-day global). This is a different operation involving transplanted muscle and should not be confused with levatorplasty.
- Preoperative anorectal manometry and endoanal ultrasound results must be documented to support the diagnosis of sphincter defect and medical necessity for surgical repair.
- 90-day global period: wound care and routine postoperative visits are bundled. Biofeedback (CPT 90911-90913) initiated during the global period by physical therapy is a separate billable service and is not bundled into the surgical fee.
- Sacral nerve stimulation (SNS/InterStim) is an alternative or adjunct to sphincteroplasty and uses an entirely different CPT family: 64561 (percutaneous sacral electrode placement, 5.30 wRVU), 64581 (open sacral electrode placement, 11.90 wRVU), and 64590 (pulse generator insertion/replacement, 4.97 wRVU). Do not use 64568, which is a cranial/vagus nerve stimulator code.
General coding reference. Verify with your institution’s billing department before submitting claims.