Transanal Excision / TAMIS

CPT 45171
Approach Minimally Invasive
Add-on / Variant CPTs
  • 45172 — Transanal excision, full-thickness (large or complicated)
  • 0184T — TAMIS (transanal minimally invasive surgery) — contractor-priced; verify payer coverage
Preoperative Diagnosis:

Rectal neoplasm / villous adenoma / early rectal cancer (T1)

Postoperative Diagnosis:

Same

Procedure Performed:

Transanal minimally invasive surgery (TAMIS), full-thickness transanal excision of rectal lesion

Attending Surgeon:

[Attending name], MD

First Assistant:

[Resident/Fellow/PA name]

Anesthesia:

General or spinal
Patient positioned in [lithotomy / prone jackknife] position based on lesion location.

Indications:

Patient presents with [benign rectal polyp / T1 rectal adenocarcinoma / carcinoid tumor] at [X] cm from the anal verge on the [anterior / posterior / lateral] wall. Lesion [not amenable to / failed] endoscopic resection. Staging MRI and endorectal ultrasound performed; no evidence of lymph node involvement. Full-thickness local excision planned. Risks including bleeding, infection, fistula, and need for radical resection if margins positive discussed.

Findings:

Under anesthesia, the lesion was identified at [X] cm from the anal verge on the [clock] wall, measuring approximately [X] cm. The lesion appeared [pedunculated / sessile / flat]. No gross evidence of invasion beyond the submucosa. A 1-2 cm margin was marked circumferentially.

Description of Procedure:

The patient was taken to the operating room, positioned in [lithotomy / prone jackknife] position, and prepped and draped in sterile fashion. The GelPOINT Path transanal access platform was inserted and secured. The working channel was insufflated with CO2 to [10-15] mmHg to maintain pneumorectum. Laparoscopic instruments (5-mm 30-degree scope, graspers, electrosurgical device) were introduced.
The lesion was identified [X] cm from the anal verge. A circumferential marking was made 1 cm beyond the lesion borders using cautery. Full-thickness excision was performed using [monopolar cautery / ultrasonic shears], starting at the distal margin and proceeding circumferentially. The mesorectal fat was visualized confirming full-thickness excision. The specimen was removed intact through the platform.
The defect measured approximately [X x Y] cm. [The defect was closed transversely with a running 2-0 Vicryl suture / The defect was left open.] Hemostasis confirmed. The platform was removed. The patient tolerated the procedure well.

Complications:

None

Specimens:

Rectal lesion, full-thickness excision, orientation stitch at [position], sent for permanent pathology

Estimated Blood Loss:

Minimal

Drains:

None

Disposition:

Patient was taken to PACU in stable condition. [Same-day discharge / Overnight observation.]

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: [Rectal villous adenoma / T1 rectal adenocarcinoma / rectal carcinoid] at *** cm from anal verge
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Transanal minimally invasive surgery (TAMIS), full-thickness transanal excision of rectal lesion
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General / spinal

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with a [benign rectal polyp / T1 rectal adenocarcinoma] at *** cm from the anal verge on the *** wall not amenable to endoscopic resection. Staging MRI and endorectal ultrasound showed no lymph node involvement. Risks including bleeding, infection, fistula, and need for radical resection if margins positive were discussed. Informed consent obtained.

FINDINGS: Under anesthesia, the lesion was identified at *** cm from the anal verge at the *** o'clock position, measuring approximately *** cm, appearing [sessile / flat / pedunculated]. No gross evidence of submucosal invasion. A 1-cm margin was marked circumferentially.

DESCRIPTION OF PROCEDURE:
The patient was positioned in [lithotomy / prone jackknife] position and prepped in sterile fashion. The GelPOINT Path transanal access platform was inserted and secured. The working channel was insufflated with CO2 to 12 mmHg maintaining pneumorectum. A 5-mm 30-degree scope and laparoscopic instruments were introduced. Circumferential marking was made 1 cm beyond lesion borders using cautery. Full-thickness excision performed using [monopolar cautery / ultrasonic shears] from distal margin circumferentially; mesorectal fat visualized confirming full-thickness excision. Specimen removed intact; orientation stitch placed at *** position. Defect measured *** × *** cm and was [closed transversely with running 2-0 Vicryl / left open]. Hemostasis confirmed. Platform removed. Patient tolerated the procedure well.

ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Rectal lesion, full-thickness excision, orientation stitch at *** position, sent for permanent pathology
COMPLICATIONS: None
DRAINS: None
DISPOSITION: Patient taken to PACU in stable condition. [Same-day discharge / Overnight observation.]

Signed: .ME, .MYDEGREE
.TODAY
Variants

Traditional transanal excision (no platform)

For low-lying lesions <5 cm from anal verge. Retractor-assisted approach. Document retractor type and lesion exposure.

TEM (transanal endoscopic microsurgery)

Rigid TEM platform. Document platform size (40mm), working length, and closure technique.

Charting Tips
  • Document distance from anal verge precisely, as this governs staging and adjuvant decisions
  • State clock position and quadrant of lesion relative to anal verge
  • Document full-thickness confirmation (mesorectal fat visualized)
  • Note whether defect was closed or left open
  • Specimen orientation suture placement must match pathology request
  • If margins positive on final pathology, document discussion of radical resection
Billing Tips
  • Bill 45171 for transanal excision of rectal tumor, partial thickness (7.93 wRVU, 90-day global). Use for sessile polyp excision or early T1 rectal lesion not involving full thickness of the wall.
  • Bill 45172 for transanal excision with full thickness resection (11.83 wRVU, 90-day global). Use when full thickness excision of the rectal wall is performed. TAMIS (transanal minimally invasive surgery) typically uses 45172.
  • Code selection is based on depth of excision, not the platform used (rigid proctoscope vs. TAMIS port vs. TEM). Document depth of excision explicitly: partial thickness (into but not through muscularis propria) vs. full thickness (through all layers).
  • 90-day global period: postoperative proctoscopy, wound assessment, and pathology review coordination are bundled. Adjuvant radiation or chemoradiation for unexpected T2+ disease is managed by oncology and does not affect surgical billing.
  • Postoperative pathology upstaging (T2 or higher on final path) requires multidisciplinary discussion. Document the intraoperative impression vs. final pathology and the subsequent clinical decision-making for medicolegal completeness.