CCSD code H3320 – Abdominoperineal resection of rectum

Key takeaways

CCSD code H3320 covers open abdominoperineal resection of the rectum and anus, which removes the anal sphincter and leaves a permanent end colostomy.

The operative approach decides the code: laparoscopic APR is H3322 and robotic-assisted APR is H3324, so H3320 is for the open operation only.

Sphincter-preserving anterior resections have their own codes: H3332 and H3334 (open), H3364 and H3365 (laparoscopic), and H3370, H3373 or the H3367/H3368 pair (robotic).

CCSD lists H3310, H3322, H3332 and H3334 among the unacceptable combinations with H3320, so they are never billed together for one operation.

Pabau, the practice management platform we build, sends insurer claims through Healthcode and tracks each one using the details already on the patient record.

CCSD code H3320: Definition and clinical scope

CCSD code H3320 is the UK private-insurance procedure code for open abdominoperineal resection of the rectum and anus. The operation removes the rectum, the anal canal and the anal sphincters in one combined procedure. Because the anus is excised, bowel continuity cannot be restored, and the patient leaves theatre with a permanent end colostomy.

The code belongs to the Clinical Coding and Schedule Development (CCSD) schedule, which UK private medical insurers use to identify procedures. Bupa, AXA Health, Aviva and Vitality all work from it, and practices usually submit claims through Healthcode. H3320 sits in CCSD sub-chapter 11.6 Rectum/anus. Guides to other codes in the schedule sit in our CCSD procedure codes index.

The procedure is also known as APR or the Miles operation, after William Ernest Miles, who described the combined abdominal and perineal approach in 1908. H3320 applies only when the whole operation is performed open. Laparoscopic and robotic-assisted versions have codes of their own.

The abdominoperineal resection procedure: Clinical overview

APR is a two-phase operation, performed in sequence by one surgeon or at the same time by two teams. Coders need to recognise both phases in the operative note to support an H3320 claim.

1. Abdominal phase: The surgeon divides the sigmoid colon, ligates the inferior mesenteric vessels and mobilises the rectum down to the pelvic floor. The sigmoid colon is then brought out through the left iliac fossa as a permanent end colostomy.
2. Perineal phase: With the patient in the Lloyd-Davies or prone position, the anus is closed with a purse-string suture. The surgeon then excises the anorectal stump, the sphincter complex and the surrounding ischioanal fat, and closes the perineal wound.
3. Specimen retrieval: The rectum, anus and sphincters come out as one specimen. It goes to histopathology to confirm the margins and the tumour stage.

Clinical indications: When H3320 is performed

Surgeons choose APR when the sphincter cannot be kept without compromising the operation. The main indications are:

• Low rectal cancer that sits too close to the sphincters for a safe sphincter-preserving resection.
• Squamous cell carcinoma of the anal canal, usually as salvage surgery when chemoradiotherapy has not cleared the tumour.
• Severe perianal Crohn’s disease in selected patients, where reconstruction is not feasible.

The indication should appear in the operative note and match the ICD-10 code on the claim. The diagnosis section below lists the usual pairings.

What CCSD code H3320 includes and excludes

Knowing what H3320 covers prevents under-billing and unbundling. The table sets out the main components and where each one sits.

H3320 vs other abdominoperineal codes

CCSD splits abdominoperineal surgery by approach and by what happens to the anus. Picking the wrong sibling is the most common way an H3320 claim goes back to the practice.

If a laparoscopic APR is converted to open, record the conversion and the stage at which it happened. Then check the CCSD coding principles and the insurer’s policy before choosing between H3322 and H3320. Where the abdominal phase stays laparoscopic, H3322 is the code to bill.

The CCSD schedule also keeps one non-resection code off an H3320 claim. H4430, examination of rectum under anaesthetic, applies only when the examination is the sole procedure. Its entry names H3320 as an unacceptable combination, so an examination under anaesthetic drops off the APR claim.

H3320 vs anterior resection codes

The deciding question for any rectal resection is whether the anal sphincter survives. An anterior resection keeps it and joins the colon to the rectum, while H3320 removes it. CCSD codes anterior resections by approach and by the level of the join.

Where the sphincter is preserved, the level of the join decides the laparoscopic code. H3364 covers a laparoscopic high anterior resection, with the colorectal anastomosis above the peritoneal reflection. H3365 applies once that join sits at or below it. The open codes divide at the same point. H3332 is the open high anterior resection, and H3334 applies once the join sits at or below the peritoneal reflection.

CCSD lists H3332 and H3334 among the unacceptable combinations with H3320. If the operative note describes a colorectal or colo-anal anastomosis, the sphincter was kept and H3320 does not apply. If it confirms perineal dissection and a permanent end colostomy, H3320 is correct for an open operation.

The grid below puts the two deciding facts together. Read the sphincter outcome first, then the approach, and the code follows.

ICD-10 diagnosis codes paired with H3320

UK insurers expect a diagnosis code that matches the documented operative findings. UK practice uses the WHO ICD-10 classification, and these are the codes most often paired with H3320.

The diagnosis code should reflect the operative and histology findings, not only the pre-operative diagnosis. If histology reclassifies the tumour, for example from C20 to C21.1, an amended claim with the corrected ICD-10 code may be needed.

Pre-authorisation requirements from UK insurers

UK private medical insurers generally expect the patient to obtain pre-authorisation before planned surgery such as APR. The authorisation number should appear on the claim, and it should name the same procedure the surgeon performed.

If the plan changes, for example from a laparoscopic to an open approach, tell the insurer. An authorisation issued for H3322 does not automatically cover a claim coded H3320. Each insurer sets its own rules, so confirm them before the operation date.

Documentation requirements for H3320 claims

Insurers review major colorectal claims closely. The operative note should confirm the following to support H3320:

• Both phases: the abdominal phase (mobilisation, sigmoid division and vessel ligation) and the perineal phase (anorectal excision and sphincter removal).
• The approach: a clear statement that the operation was open, plus any conversion from laparoscopic or robotic surgery.
• Sphincter removal: explicit confirmation, because without it an insurer may query whether an anterior resection code applies.
• Colostomy details: the site and the type of end colostomy formed.
• Specimen and wound: the specimen sent to histopathology, and how the perineal wound was managed.
• Authorisation: the insurer’s pre-authorisation number for the procedure.

Why H3320 claims get queried and how to prevent it

APR claims draw more questions than most colorectal codes because the clinical and administrative records have to agree. The most frequent causes are:

• Approach mismatch: H3320 billed for a laparoscopic or robotic operation that should be H3322 or H3324.
• Missing authorisation: no pre-authorisation number, or one issued for a different procedure code.
• Unclear operative note: the note describes a rectal resection but never confirms sphincter removal or perineal dissection.
• Unacceptable combinations: H3320 billed alongside H3310, H3322, H3332 or H3334 for the same operation.
• ICD-10 mismatch: for example, C20 coded for an anal canal primary that should be C21.1.

How to respond to a queried H3320 claim

1. Read the insurer’s reason on the remittance or rejection message before changing the claim.
2. Correct the code or diagnosis if the query is valid, then resubmit through Healthcode.
3. Send supporting evidence if the code is right: the operative note, the authorisation and the histology report.
4. Contact the insurer’s provider team if the query is still unresolved, and keep a record of each exchange.

Submitting H3320 claims to UK insurers with Pabau

Surgical practices billing H3320 tend to lose time in the same places: authorisation numbers kept in emails, invoices typed twice, and claims nobody follows up. Pabau keeps the patient, the insurer details and the invoice on one record.

From that record, Pabau’s claims management software builds the claim from the details already on file and sends it through Healthcode. Your team then tracks each claim’s status in one place. Pabau does not choose the CCSD or ICD-10 codes, so the coder’s decision stays with the coder.

The outcome is fewer claims stuck in a spreadsheet and a clear view of which insurer owes a response. For the wider picture of how insurers apply the schedule, see the Bupa CCSD codes guide.

Send cleaner H3320 claims to UK insurers

Pabau builds each claim from the patient, insurer and invoice details already on file. It sends the claim through Healthcode and tracks it until it is settled.

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Conclusion

H3320 is a narrow code: open abdominoperineal resection, sphincters removed, permanent end colostomy. Every other rectal resection, whether laparoscopic, robotic or sphincter-preserving, has its own CCSD code. The operative note is what proves which one applies.

Code from the note, authorise the exact procedure and match the ICD-10 code to the tumour site. Those three habits remove the most common reasons for a query. To see how Pabau keeps CCSD claims moving through Healthcode, book a demo.

Continue your research

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