Gastroenterology Coding Alert

Coding Tips to Help Increase Your Confidence and Reimbursement

Gastroenterologists frequently manage hemorrhoids, yet those little devils can prove complicated to code, depending on their type, the number of hemorrhoids, the CPT codes used for treatment, and the location of treatment.
 
Exploring the general issues surrounding hemorrhoid treatment, and examining common "hemorrhoid" scenarios gastroenterologists face, will give you the information - and confidence - to take the burn out of hemorrhoid coding. With these expert tips, you'll report hemorrhoids accurately and to the best advantage of your practice.

1. Know Hemorrhoid Types and Degree
 
When coding for hemorrhoid treatment, your first step is to classify the type of hemorrhoid(s) involved. There are two main types of hemorrhoids: internal (455.0-455.2) and external (455.3-455.5).
  
The eMedicine Web site defines hemorrhoids as "varicosities of the hemorrhoidal venous plexus." Internal hemorrhoids occur inside the anal canal, "above the dentate line, are covered by anal mucosa and lack sensory innervation." Their venous drainage proceeds "into the superior rectal vein, which drains into the portal system." External hemorrhoids develop near the anal opening, "below the dentate line and are covered by stratified squamous epithelium with innervation by the inferior rectal nerve. External hemorrhoids drain into the inferior rectal vein, which drains into the inferior vena cava."
 
Both internal and external hemorrhoids can occur in a patient at the same time. Internal hemorrhoids have four stages of severity:
 

First degree: The hemorrhoid does not protrude from the anus.
 

Second degree: The hemorrhoid protrudes from the anus during a bowel movement but spontaneously returns to the anal canal afterward.
 

Third degree: The hemorrhoid protrudes from the anus during a bowel movement, but you can push it inside the anus with your finger.
 

Fourth degree: The hemorrhoid is always outside the anus and cannot be pushed into the anal canal.

2. Choose Treatment for Internal Hemorrhoids

The treatments for hemorrhoids - and the codes for hemorrhoid treatment services - differ depending on where they develop. In some cases, hemorrhoids must be treated endoscopically or surgically. These methods are used to shrink and/or destroy the hemorrhoidal tissue. The doctor can perform the procedure in the office, at an ambulatory surgery center, or at a hospital outpatient surgery unit. A gastroenterologist or surgeon can perform the various hemorrhoid procedures depending on the required technical aspects.
 
Gastroenterologists most commonly deal with internal hemorrhoids. GI physicians either see a patient for hemorrhoids at the request of a primary-care physician (PCP) or discover internal hemorrhoids while performing other procedures, says Linda Parks, MA, CPC, CCP, business office coordinator, GI Diagnostics Endoscopy Center. PCPs will more often than not refer cases of external hemorrhoids to a surgeon for patient care and treatment, as will most gastroenterologists when they see a patient with the external variety. Gastroenterologists occasional perform the more minor temporary treatments for external hemorrhoids including incision and removal of an external hemorrhoid thrombosis (46083).
 
Gastroenterologists most commonly use simple rubber-band ligature (46221, Hemorrhoidectomy, by simple ligature [e.g., rubber band]) to remove hemorrhoids, Parks says. In this procedure, the physician "ties off" (ligates) the hemorrhoid at its base inside the rectum. The band cuts off its blood supply and causes it to shrivel and fall off over time.
 
For patients who require simple hemorrhoid removal by ligature, or "banding," the gastroenterologist might remove more than one hemorrhoid during the same session. Although some carriers may pay for each hemorrhoid removed, most 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.
  
Aside from rubber-band ligature, CPT provides additional codes to describe less-frequently used methods of removing internal hemorrhoids, none of which are described by hemorrhoidectomy codes 46221-46262. These include:
 

Sclerotherapy. In this procedure, coded 46500* (Injection of sclerosing solution, hemorrhoids), the surgeon injects a sclerosing solution into the submucosa of the rectal wall under the hemorrhoid. This procedure is designed to reduce blood flow to the area and cause the hemorrhoid to shrink.
 

Infrared coagulation. Covered under a series of general "destruction of hemorrhoids" codes (46934, Destruction of hemorrhoids, any method; internal; 46935, ... external; and 46936, ... internal and external) that describe any method of destruction, physicians using this treatment option burn the hemorrhoidal tissue using infrared radiation.
 
Because CPT uses the plural "hemorrhoids" in its definition of 46934 (as well as 46935 and 46936), you should report this code only once per session, regardless of how many hemorrhoids the physician treats, says Barbara Johnson, CPC, a coding expert with Loma Linda University Medical Group.

3. Symptoms or Diagnoses: Know the Codes

Gastroenterologists often see patients for hemorrhoids at the request of a PCP who has diagnosed the patient with internal hemorrhoids. A patient might also present without a hemorrhoid diagnosis but have symptoms of rectal pain (569.42, Anal or rectal pain) and possibly rectal bleeding (569.3, Hemorrhage of rectum and anus).
 
"Usually rectal pain brings the patient in for a flexible sigmoidoscopy (45330-45345) for hemorrhoids. If they haven't already done it at the PCP and they come to us with the rectal pain, our physician will do a rectal exam. If he can feel the hemorrhoid, then he will usually schedule a flex sig. While [the doctor's] in the flex, he'll do the banding," Parks says.
 
Sometimes the physician finds hemorrhoids in the course of conducting another procedure. For instance, a patient comes in for a screening flex, during which the gastroenterologist notices internal hemorrhoids. Generally, unless they're causing a problem for the patient, the physician will leave the hemorrhoids alone, Parks says. "Usually a patient has to have a symptom, like rectal pain, for the GI doc to do anything about the hemorrhoids. If they're not bothering [the patient], the doctor usually doesn't do anything with them," she adds.
 
There are times, however, when a patient might come in to see the gastroenterologist for a condition - without stating any explicit symptoms for hemorrhoids - but the physician finds the hemorrhoids problematic and in need of treatment. For instance, a PCP sends a patient who has symptoms of diarrhea (787.91), severe cramping (789.0x) and possible irritable bowel syndrome (IBS, 564.1) to a gastroenterologist. The gastroenterologist performs a diagnostic flex sig or colonoscopy (45355-45387) and finds hemorrhoids that she feels need treatment.
 
Parks suggests some of the characteristics that might lead the gastroenterologist to recommend treatment for the hemorrhoids - if not to band them during the procedure itself:
 

Size. A physician might band what she thinks are overly large and potentially problematic hemorrhoids.
 

Bleeding. If a physician finds a bleeding hemorrhoid, he might band it.
 

Redness or irritation. Either or both might suggest that the patient has or will have problems with the hemorrhoids, and might lead a gastroenterologist to treat them.
 

Irregularity. Some hemorrhoids can actually twist around on themselves, suggesting problems in the future.

4. Code Complications in the Global Period
 
One thing to remember when coding 46221 is that the procedure comes with a 10-day global period. "So if the patient comes back in during the 10 days following the banding, you won't get paid for it," Parks says. General complications in the follow-up period of band ligation include bleeding or severe rectal pain.
 
You can file for and receive reimbursement if complications in the global period require an additional trip to the endoscopy center. "If you have to go back in and do another scope, you can get paid for that if you use a modifier." Append modifier -78 (Return to the operating room for a related procedure during the postoperative period) to the procedure code to ensure reimbursement.

5. Consider Site of Service, Too

Whether or not a gastroenterologist treats hemorrhoids during a flex sig or colonoscopy can have a lot to do with where the procedure is taking place.
 
Many gastroenterologists, like those in Parks' practice, perform hemorrhoid ligatures in an endoscopy center rather than in their office because many do not have the equipment for banding in their offices. In such a case, if the physician initiates care in the office and discovers hemorrhoids during an in-office flex sig, the doctor and the patient must discuss treatment options. If they decide to band the hemorrhoid, the practice will make a follow-up appointment in the endoscopy facility, where the physician will perform the procedure.
 
Parks says that flex sigs are not approved for an ambulatory service center or outpatient center. "The center won't get paid for it; you must do something with that flex," she says. Given this, if a physician were to examine a potential IBS patient like the one mentioned above or a patient who comes to the office without a firm diagnosis of hemorrhoid, then that patient would likely be seen in the office first for evaluation and management services and perhaps a flex sig performed in the office setting rather than at an endoscopy center. If the physician finds hemorrhoids in such a case - even problem hemorrhoids - the patient must be scheduled for an appointment at an endoscopy center.
 
On the other hand, "if we know the patient is coming in for hemorrhoid treatment, we schedule it at the endoscopy center," Parks says. She also reminds coders that the hemorrhoid treatment - 46221 or 46934 - has a higher relative value unit (it pays more) than the flex sig, so report the hemorrhoid procedure first. The same holds true if you're seeing a patient for a colonoscopy screen in the endoscopy center and necessary hemorrhoid treatment takes place. Make sure you record that procedure first and capture the revenue you've earned.