Gastroenterology Coding Alert

Hint:  Use combined code for internal/external hemorrhoid procedures, not 1 internal and 1 external code

Many gastroenterology coders automatically reach for 46221 to describe hemorrhoid removals. But your potential choices are more varied.
 
In some cases, the physician may choose sclerotherapy or other methods to treat hemorrhoids, and reporting 46221 is incorrect for these methods. Follow these five tips to ensure you-re choosing the right code every time.

1. Determine Hemorrhoid Location

As a first step, 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 surgeon, 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 (which is the type gastroenterologists most often treat) 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 gastroenterologist before progressing.

2. Report 1 Unit of Ligature Only

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 gastroenterologist may remove more than one hemorrhoid by simple ligature during the same session. Although some carriers may pay for each hemorrhoid removed, the vast majority will not. The AMA's CPT Assistant (October 1997) instructs physicians to bill 46221 only once per operative session regardless of how many hemorrhoids they band 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. Keep in mind: These procedures are rare in a GI practice.

4. Gastro Relies on 2 External Codes

CPT includes an entire range of codes to describe external hemorrhoid removal, but gastro coders should be concerned mainly with 46083 (Incision of thrombosed hemorrhoid, external) and 46935 (Destruction of hemorrhoids, any method; external).

Code 46083 describes removal by simple incision (drainage), while 46935--like 46934 (Destruction of hemorrhoids, any method; internal: see related article later in this issue)--can include electrical current, infrared radiation and other methods and applies to one or more hemorrhoids, says Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Lawrenceville, Ga.

5. Call on 46936 for Same-Session Internal/External

If the gastroenterologist removes both external and internal hemorrhoids during the same session, report 46936 (Destruction of hemorrhoids, any method; internal and external) rather than one internal and one external code. Code 46936 describes destruction of internal and external hemorrhoids by any method other than excision.