Gastroenterology Coding Alert

A hemorrhoid's location should lead you to the appropriate ICD-9.

Want to get your hemorrhoid report right and stress-free? You can start by knowing the difference between internal and external hemorrhoids, but you can learn more from this sample physician's report:

PREPROCEDURE DIAGNOSIS: History of colon polyps and partial colon resection, right colon.

POSTPROCEDURE DIAGNOSES:

1. Normal operative site.

2. Mild diverticulosis of the sigmoid colon.

3. Internal hemorrhoids.

PROCEDURE: Total colonoscopy.

PROCEDURE IN DETAIL: The 60-year-old patient presents to the office to be evaluated for the preprocedure diagnosis. The patient also apparently had an x-ray done at the hospital and it showed a dark spot, and because of this, a colonoscopy was felt to be needed. She was prepped the night before and on the morning of the test with oral Fleet's, brought to the second floor and sedated with a total of 50 mg of Demerol and 3.75 mg of Versed IV push. Digital rectal exam was done, unremarkable. At that point, the Pentax video colonoscope was inserted. The rectal vault appeared normal. The sigmoid showed diverticula throughout, mild to moderate in nature. The scope was then passed through the descending and transverse colon over to the hepatic flexure area and then the anastomosis site was visualized. The scope was passed a short distance up the ileum, which appeared normal. The scope was then withdrawn through the transverse, descending, sigmoid, and rectal vault area. The scope was then retroflexed, and anal verge visualized showed some internal hemorrhoids.

RECOMMENDATIONS: Repeat colonoscopy in three years.

Let Location Guide You

You can easily identify external hemorrhoids (455.3-455.5) because of its place of appearance. This type of hemorrhoid has a fleshy growth and occurs around the anus -- specifically, outside the anal verge which is at the distal end of the anal canal. On the other hand, internal hemorrhoids (455.0-455.2) occur inside the anal canal. The veins lining the walls of the rectum become enlarged (blood clot) and bulge out.

Another way to distinguish internal from external hemorrhoids is by looking at their location compared to the dentate line. The line is a mucocutaneous junction about a centimeter above the anal verge and can be seen separating the anus from the rectum. While internal hemorrhoids take place above the dentate line, external hemorrhoids take place below the line.

Ideal: While you may learn to differentiate one hemorrhoid type from the other through years of practice, you could dodge coding errors by asking your physicians to indicate "internal" or "external" in their notes.

Tread Through Hemorrhoid Excision Codes Cautiously

By adding the following text note, CPT 2010 gives you the permission to use certain codes for excision of internal and/or external hemorrhoids: "For excision of internal and external hemorrhoids, see 46250-46262, 46320." This means you can opt for 46255 (Hemorrhoidectomy, internal and external, single column/group) or 46260 (Hemorrhoidectomy, internal and external, 2 or more columns/groups) for excision of multiple internal hemorrhoids.

You may go for 46945 (Hemorrhoidectomy, internal, by ligation other than rubber band; single hemorrhoid column/group) or 46946 (Hemorrhoidectomy, internal, by ligation other than rubber band; 2 or more hemorrhoid columns/groups) for some internal hemorrhoid excisions.

How it's done: Known as "transfixion suture excision," the surgeon places a crisscross stitch and ties off the base of the hemorrhoid with the suture (ligation) to take control of the bleeding. Post this, the surgeon excises and removes the remaining hemorrhoid.

Alternatives: Sometimes a physician would inject solution to cause the hemorrhoid to harden and shrivel. In this case, you should report 46500 (Injection of sclerosing solution, hemorrhoids). For thermal destruction, you should bill 46930 (Destruction of internal hemorrhoid[s] by thermal energy [e.g., infrared coagulation, cautery, radiofrequency]). CPT 46999 (Unlisted procedure, anus) would fit a destruction by cryosurgery.

Observe Symptoms Your Patient Exhibits

A patient might present to the office without a hemorrhoid diagnosis, but symptoms such as rectal pain (569.42, Anal or rectal pain) or rectal bleeding (569.3, Hemorrhage of rectum and anus) could give away the condition. During the office visit, the physician will usually perform an inspection of the external and she may add an anoscopy to look specifically for internal hemorrhoids or another cause of bleeding.

You would report the office visit with the following codes:

• An E/M code for the visit depending on the complexity and documentation (i.e., 99202-99205) along with modifier 25 (Significant, separately identifiable E&M service by the same physician on the same day of a procedure or other service);
• 46600 (Anoscopy; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]);
• 569.42, (Anal or rectal pain) or 569.3, (Hemorrhage of rectum and anus) for the patient's symptoms.

Sometimes the patient gets diagnosed with hemorrhoids in the course of undergoing another procedure. This is the case in our example where the patient comes for a screening colonoscopy during which the gastroenterologist notices internal hemorrhoids. Generally, unless they're causing a problem for the patient, the physician will leave the hemorrhoids alone, says Linda Parks, MA, CPC, CCP, business office coordinator, GI Diagnostics Endoscopy Center. "Usually a patient has to have a symptom, like rectal pain, for the GI doc to do anything about the hemorrhoids," she explains. The physician usually doesn't do anything with hemorrhoids unless the patient complains he is bothered by it.

You would report the example given above using the following codes:

• G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) to describe the screening colonoscopy for high-risk patient;
• V12.72 (Personal history of diseases of digestive-system; colonic polyps) linked to G0105 to prove medical necessity for the visit;
• 562.10 (Diverticulosis of colon [without hemorrhage]) for the diverticulosis of the sigmoid colon linked to G0105;
• 455.0 (Internal hemorrhoids without complication) G0105 to describe the internal hemorrhoids.

Reminder: Medicare patients aged 50 and above are entitled to a screening colonoscopy once every 10 years. You should bill non high-risk encounters with G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).