Gastroenterology Coding Alert

Removal method notes help guide you to the right code.

When your gastroenterologist performs internal hemorrhoid removals in the office, you'll stand a better chance of recouping for those services if you've looked closely at hemorrhoid location and specific removal method. Take this quick refresher on coding basics.

Look for Location and Anesthesia to Ascertain Type

To accurately report a hemorrhoid-related procedure, you should first identify the hemorrhoid type. Hemorrhoids are a plexus of veins present in the anal canal, veins that aid the smooth movement of stools and send back blood from the anal canal to the heart. These veins cause concern only when they become inflamed or begin to bleed. Hemorrhoids are often distinguished by relation to the dentate line, which is a mucocutaneous junction found about 1-1.5cms higher than the anal verge. Accordingly, hemorrhoids are classified as internal (above dentate line), external (below dentate line) or mixed types (originating higher than dentate line and extending beyond it).

Some clues to watch out for: Look for documentation of hemorrhoid type (external or internal), and references to the dentate line to narrow down your code choice.

A second clue is in the type of anesthesia used. If local anesthesia has been used during the procedure, then the procedure is definitely external. For internal hemorrhoid removal procedures, such as band ligation or cautery, no anesthesia is needed as the procedure will not elicit any pain. However, for excision of an external hemorrhoid, general anesthesia or spinal anesthesia is typically used, although some surgeons might use local anesthesia also. But, being a surgical procedure, this is not something that your gastroenterologist will attempt in the office.

"While these clues might help a coder to determine the internal or external designation, it is important to talk to your gastroenterologist about improving their documentation," says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT® Advisory Panel. "If you mention improved reimbursement, then most physicians will change their behavior."

Turn to Procedure for Internal Hemorrhoids

When you have ascertained that your gastroenterologist is working on internal hemorrhoids, look closely to determine how exactly the hemorrhoids were treated. Injections of sclerosing solutions, ligation, cautery, and coagulation are some common methods your gastroenterologist will use. You would report these with the following codes:

• For ligations using a rubber band, the most common type of removal procedure for an internal hemorrhoid, you would report code 46221 (Hemorrhoidectomy, internal, by rubber band ligation[s]).
• If your gastroenterologist prefers to use a sclerosing agent which he injects into the rectal submucosa just below the level of the hemorrhoid, you report code 46500 (Injection of sclerosing solution, hemorrhoids).
• If your physician opts for cautery, infrared or radiofrequency, to obliterate the internal hemorrhoid, you need to code the procedure as 46930 (Destruction of internal hemorrhoid[s] by thermal energy [eg, infrared coagulation, cautery, radiofrequency]).

Exception: When reporting procedures for hemorrhoids, remember that gastroenterologists do not generally perform more invasive types of hemorrhoid removal procedures such as combined removal of 'internal and external' hemorrhoids in a single group. These types of procedures are usually performed by surgeons.

Note: "Do not overuse 46221," says Weinstein. "The most common method used by gastroenterologists for internal hemorrhoids is rubber band ligation. The procedure report may contain the phrase "band ligator", "CRH O'Regan system", or "multi-band ligator". For any of these hemorrhoid removals, the correct code is 46221 used just once even if multiple bands are performed during the procedure."

Count the Columns in Mixed Hemorrhoids

In case of mixed hemorrhoids (the origin is above dentate line and growth beyond it), you need to code the removal procedure under 46255 (Hemorrhoidectomy, internal and external, single column/group) and 46260 (Hemorrhoidectomy, internal and external, 2 or more columns/groups) depending upon the number of columns or group of hemorrhoids that your gastroenterologist is treating.

According to CPT® guidelines, three different positions in the anal canal will form anal columns: right posterior, right anterior and left lateral positions. When your physician removes more than one hemorrhoid by a non-rubber band technique, you need to concentrate on the number of columns from which the hemorrhoids have been removed rather than the actual number of hemorrhoids.

Coding Tips: If you encounter a situation wherein your physician has treated external and internal hemorrhoids (not a mixed hemorrhoid), then you cannot code it under 46255 or 46260. Instead, you will have to code the two procedures separately for removal under the apt code for the procedures.

Ascertain Incision vs. Excision in External Hemorrhoids

Some gastroenterologists will treat painful external hemorrhoids in the office setting. When coding for external hemorrhoid services, you need to check the note for the presence of thrombosis (clotting).

"If thrombosis is present, you report the condition based on the procedure done and in general the gastroenterologist will only be removing the clot to provide relief of discomfort," says Weinstein. If your gastroenterologist has actually done an excision of an external hemorrhoid, then you report 46320 (Excision of thrombosed hemorrhoid, external). If the clot has been eliminated through incision and drainage, then you report 46083 (Incision of thrombosed hemorrhoid, external).

In some cases, your gastroenterologist might wait for a skin tag to form, following which he may decide whether or not to excise it. If excision is the method of choice, you will need to report it under 46220 (Excision of single external papilla or tag, anus) or 46230 (Excision of multiple external papillae or tags, anus) based on the number of tags formed.