CODING CORNER: Your 5-Step Guide to Flawless Hemorrhoid Removal Claims

Opt for 1 internal-external code when possible

Old habits die hard--and defaulting to 46221 for all hemorrhoid removals is a tough one to break. But for many hemorrhoid removals, the physician may choose sclerotherapy or other methods, which means 46221 isn’t the code to pick. Use this step-by-step approach to breathe new life into coding these procedures.
1. Determine Hemorrhoid Location
For starters, you must classify the type of hemorrhoid(s) involved.
“Hemorrhoids are either internal or external,” says M. Trayser Dunaway, MD, FACS, CSP, CHCO, CHCC, a physician and coding educator and healthcare consultant in Camden, S.C. “In some cases, the physician may deal with both kinds during the same session. But whatever the circumstances, the codes you’ll report are directly related to the location of the hemorrhoids involved.”
Dentate line is key: An internal hemorrhoid (the type that usually receives surgical treatment) originates above the dentate line (a mucocutaneous junction that lies about 1 to 1.5 cm above the anal verge). In contrast, an external hemorrhoid originates below this line.
“If the physician does not directly state ‘internal’ or ‘external’ hemorrhoid, you can read further into the documentation to see if there is a reference to the dentate line,” Dunaway says. If the documentation is unclear, you should be sure to consult with the physician before progressing.
2. Report Only 1 Unit of Ligature
If the physician “ties off” (ligates) the hemorrhoid at its base to cut off its blood supply--which causes the hemorrhoid to shrink over time--you should select 46221 (Hemorrhoidectomy, by simple ligature [e.g., rubber band]). “By far the most common hemorrhoid removal procedure is simple rubber-band ligature,” Dunaway says.
The physician may remove more than one hemorrhoid by simple ligature during the same session. Although some intermediaries may pay for each hemorrhoid removed, the vast majority will not.
The AMA’s CPT Assistant (October 1997) instructs you to bill 46221 only once per operative session regardless of how many hemorrhoids the physician bands at that time.
Bottom line: Even if the physician removes two or more hemorrhoids by simple ligature, you should report only a single unit of 46221.
3. Suture Ligation Differs From Rubber Banding
Be careful not to confuse so-called “suture ligation” with simple ligation, or rubber banding, as described by 46221. Suture ligation (46945, Ligation of internal hemorrhoids; single procedure; and 46946, ... multiple procedures) is an altogether different procedure in which the physician isolates the hemorrhoid and ties suture material to its base.
As with rubber banding, the hemorrhoid will slough off as the suture strangulates blood flow.
4. Rely on 2 External Codes

- Published on 2006-02-24