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, [...]