Gastroenterology Coding Alert

If you didn't know that the dentate line is the marker that separates internal hemorrhoids from external hemorrhoids, you might wind up submitting the wrong hemorrhoid-removal code.

Don't let one piece of info send you scanning through your coding manuals -- keep this hemorrhoid coding advice handy for reference instead.

Important: In all but a few cases, you will report only a single unit of a single code to describe hemorrhoid removal -- even if the physician removes multiple hemorrhoids during the same session, says Suzan Berman-Hvizdash, CPC, CPC-E/M, CPC-EDS, physician educator for the University of Pittsburgh and past member of the American Academy of Professional Coders National Advisory Board.

As a first step, you must classify the types of hemorrhoids involved.

"Hemorrhoids are either internal or external," says M. Trayser Dunaway, MD, FACS, CSP, CHCO, CHCC, a surgeon, speaker, 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.

Definition: Internal hemorrhoids occur above the dentate line and are typically lined by rectal mucosa. Rarely, acute severe bleeding requires transfusion, and, occasionally, ongoing chronic losses cause iron-deficiency anemia.

There are four types of internal hemorrhoids:

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

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

Third degree: The hemorrhoid protrudes from the anus during a bowel movement but can be pushed back into the anus.

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

When the gastro removes internal hemorrhoids, he will usually use one of the following methods:

• rubber-band ligation (46221, Hemorrhoidectomy, by simple ligature [e.g., rubber band])

• sclerotherapy (46500, Injection of sclerosing solution, hemorrhoids)

• infrared cautery (IRC) (46934, Destruction of hemorrhoids, any method; internal; 46936, ... internal and external).

Other methods: You would likely code any other method for internal hemorrhoid removal with 46934 and/or 46936 (Destruction of hemorrhoids, any method; internal and external).

Although gastroenterologists mainly treat internal-hemorrhoid patients, GIs may also treat external ones, especially if the patient has a thrombosed external hemorrhoid. External hemorrhoids occur below the dentate line and are usually covered with squamous epithelium.

Methods/codes used: The physician will likely use one of these methods to treat external hemorrhoids:

• incision (46083, Incision of thrombosed hemorrhoid, external)

• cauterization (46935, Destruction of hemorrhoids, any method; external; and/or 46936).

Exception: Unlike other methods, the incision of a thrombosed hemorrhoid (46083) describes only one removal.

Code for any other method of external-hemorrhoid removal with 46935 and/or 46936. Before filing a claim with these codes for any removal technique other than cauterization of external hemorrhoids, contact the payer.