Gastroenterology Coding Alert

Coding and reimbursement for the removal of hemorrhoids done in combination with an endoscopy can be confusing. Depending on which endoscopic procedure is performed, sometimes the endoscopy will be reimbursed at 100 percent of its allowed fee and other times the hemorrhoid removal will be reimbursed fully. In some instances, the endoscopy and the hemorrhoid removal cannot be billed at the same time because they are bundled by the Correct Coding Initiative. Unlike most endoscopy codes, these hemorrhoidectomy codes have 10- and 90-day global periods, and any reimbursable services that occur during these postoperative periods will require the attachment of a modifier to receive payment.

The removal of hemorrhoids, which are enlarged blood vessels in and around the anus and lower rectum, more commonly is performed by a colorectal or general surgeon. A gastroenterologist, however, frequently will discover internal hemorrhoids while performing a lower gastrointestinal endoscopy on the patient.

When a patient is experiencing rectal bleeding, a gastroenterologist may do a colonoscopy and find that the only possible cause of the bleeding is some hemorrhoids, notes Glenn Littenberg, MD, FACP, a gastroenterologist in Pasadena, Calif., and a member of the AMAs CPT editorial panel. The gastroenterologist may elect to treat the hemorrhoids at that time.

Report Rubber Band Ligation With Code 46221

The most common method of removal used by gastroenterologists is rubber band ligation (RBL), says Littenberg, who adds that its similar to the banding process used to treat esophageal varices. With RBL, a ligator is attached to the endoscope and used to draw up the tissue around the hemorrhoid. A rubber band is then discharged from the ligator and wrapped around the hemorrhoid. The band cuts off the circulation, and the hemorrhoid withers within a few days.

Code 46221 (hemorrhoidectomy, by simple ligature [e.g., rubber band]) should be used to report an RBL procedure, says Linda Parks, MA, CPC, lead coder at Atlanta Gastroenterology Associates, a 22-physician practice. The code can be reported only once, even though often two bands are placed around a single hemorrhoid, and several hemorrhoids are ligated during a single session.

Coding in Combination With Endoscopy

When a colonoscopy is performed in combination with an RBL, the colonoscopy will have the higher relative value unit (RVU) and will be reimbursed at 100 percent of its allowed fee. Modifier -51 (multiple procedures) should be attached to 46221, and reimbursement for that procedure will be 50 percent of the allowed fee because the multiple procedures payment rules apply.

If an RBL is done in combination with a flexible sigmoidoscopy (45330-45339), the reimbursement scheme will depend upon the particular sigmoidoscopy procedure that is performed. A diagnostic sigmoidoscopy (45330), for example, has a 2.37 nonfacility RVU, compared to a 3.39 nonfacility RVU for the RBL. In this case, 46221 would be listed first on the HCFA 1500 claim form and would be reimbursed at 100 percent of its allowed fee because it is the higher-valued procedure. Modifier -51 should be attached to 45330, and reimbursement for the flexible sigmoidoscopy will be 50 percent of the allowed fee because the multiple procedures payment rules apply.

If the gastroenterologist performs a flexible sigmoidoscopy where a polyp is removed via the snare technique (45339) and then does an RBL, 45339 should be reimbursed at 100 percent of its allowed fee because it has a 6.42 nonfacility RVU and is the higher-valued procedure. Modifier -51 should be attached to 46221, and reimbursement for the RBL will be 50 percent of the allowed fee because the multiple procedures payment rules apply.

Anoscopy Code Bundled With RBL

RBL also can be done in combination with an anoscopy or proctosigmoidoscopy, which often are performed in an office setting. Because the RBL and the anoscopy codes 46600 (anoscopy; diagnostic), 46604 (anoscopy with dilation, any method) and 46606 (anoscopy with biopsy, single or multiple) are bundled by the Correct Coding Initiative, according to Parks, both procedures cannot be reported together. She recommends in this situation that the gastroenterologist only report the RBL to the payer because it has a higher RVU than any of the three anoscopy codes.

Occasionally, the rubber bands will cause discomfort or bleeding, and another endoscopy often a flexible sigmoidoscopy has to be performed to remove them. If the patient has rectal bleeding, the gastroenterologist will do another endoscopy to make sure its really the bands that are causing it, explains Parks. Because there is no specific code for reporting the removal of the rubber band ligatures, Parks would report only the endoscopy that was performed.

For example, if a gastroenterologist performs a flexible sigmoidoscopy where some control of bleeding procedure also was performed, Parks would report code 45334 (flexible sigmoidoscopy with control of bleeding, any method) with modifier -78 (return to the operating room for a related procedure during the postoperative period) attached. This modifier needs to be used because 46221 has a 10-day global period, which means that all postoperative services provided during that period except for those that require an additional trip to the operating room or endoscopy suite are not reimbursable separately.

Use Code 46934 for Cauterization

As an alternative to RBL, some gastroenterologists may use a probe to cauterize the hemorrhoid. This method may include the use of laser coagulation, a heater probe or a direct current probe, notes Littenberg, who adds that 46934 (destruction of hemorrhoids, any method, internal) should be used to report this type of removal. In the rare situation when a gastroenterologist removes both internal and external hemorrhoids, 46936 (destruction of hemorrhoids, internal and external) should be used.

If a gastroenterologist performs a destruction of internal hemorrhoids in combination with a flexible sigmoidoscopy (45330), 46934 should be reimbursed at 100 percent of its allowed fee because it has a 7.91 nonfacility RVU, compared to a 2.37 nonfacility RVU for the sigmoidoscopy. Modifier -51 should be attached to 45330, which will be reimbursed at 50 percent of its allowed fee because the multiple procedure payment rules apply.

Modifiers Needed During Global Period

The RBL code 46221 has a global period of 10 days, and the destruction codes 46934 and 46936 have 90-day global periods. If the patient comes to the office to have the hemorrhoids evaluated during those postoperative periods, the evaluation and management (E/M) service is not reimbursable separately because it is considered covered by the fee for the procedure, says Parks.

If the patient has a problem unrelated to the hemorrhoid treatment evaluated during the global period, that E/M service is reimbursable, she explains, and modifier -24 (unrelated evaluation and management service by the same physician during a postoperative period) should be attached to the E/M code. In addition, the documentation in the patients medical record needs to clearly establish that the patient was seen for a reason unrelated to the hemorrhoid treatment.