Gastroenterology Coding Alert

Type and precise method of treatment are keys to reimbursement heaven.

Although hemorrhoids is a common ailment your GI will encounter, you may find this condition and its treatment is not so simple to code. Five rules will expose the intricacies of coding the symptoms, diagnosis and treatment options, so the next time a claim lands on your desk, you’ll know exactly what to do.

Condition: Hemorrhoids are swollen veins in the anal canal. These veins may swell and inflame due to straining oneself during bowel movements due to diarrhea or constipation . They are seen more commonly in women due to pregnancy related pressure on the veins in the pelvis both during pregnancy and especially from prolonged labor. Veins can swell inside the anal canal to form internal hemorrhoids, or they can swell near the opening of the anus to form external hemorrhoids. You can have both types at the same time. The codes for the symptoms and treatment depend on which type you have. 

Rule 1: Acquaint Yourself With Hemorrhoid Types and Degree

CPT® has classified three types of hemorrhoids: internal, external, and mixed.

Internal hemorrhoids: The origin of these types of hemorrhoids is above a real, distinguishable line, called the dentate line. The dentate line divides the anal canal from the rectum. Hemorrhoids located further inside the body are known as prolapsed internal hemorrhoids. An internal hemorrhoid will cause discomfort only if it is strangulated or incarcerated at the anal opening as the area above the dentate line lacks pain receptors. You should code internal hemorrhoids with (455.0-455.2).

Physicians classify internal hemorrhoids according to severity:

• First degree: The hemorrhoid does not protrude from the anus. 
• Second degree: The hemorrhoid protrudes from the anus during a bowel movement but returns to the anal canal afterward by itself. 
• Third degree: The hemorrhoid projects from the anus during a bowel movement, but it can be pushed inside the anus with a finger. 
• Fourth degree: The hemorrhoid is always outside the anus, and one cannot push it into the anal canal.

External hemorrhoids: The hemorrhoids develop below the dentate line near the anal opening and are covered by stratified squamous epithelium with innervation by the inferior rectal nerve. When external hemorrhoids are acutely swollen or thrombosed, they are more painful than internal hemorrhoids because they are lined with sensitive skin. Physicians usually use a local anesthetic when treating external hemorrhoids. You should code a diagnosis of external hemorrhoids with ICD-9 codes 455.3-455.5.

Mixed hemorrhoids: These hemorrhoids are a result of merging of veins from above and below the dentate line into a single area of swelling. The vein swelling may be both internal and external and picking a diagnosis code will depend on which area appears more severely involved. However, using a code for each area is acceptable. Hemorrhoids of this type often involve prolapsed mucosal tissue, along with the surrounding anoderm (skin). 

Physicians should document carefully the exact hemorrhoid type they treat if treatment is performed. If the documentation is not clear, ask for additional details. You cannot select an appropriate hemorrhoid treatment code without this information.

Rule 2: Translate Symptoms to Specific Diagnoses

Until your gastroenterologist makes a definitive hemorrhoid diagnosis, you should stick to coding the symptoms.

Example 1: A family practitioner refers the patient to a gastroenterologist after he has diagnosed the patient with internal hemorrhoids. A patient might not present with a hemorrhoid diagnosis but have related symptoms such as rectal pain (569.42, Anal or rectal pain) and/or rectal bleeding (569.3, Hemorrhage of rectum and anus). 

Example 2: A PCP sends a patient who has symptoms of diarrhea (787.91, Diarrhea NOS), severe cramping (789.0x, Abdominal pain) and possible irritable bowel syndrome (564.1, Irritable bowel syndrome) to a gastroenterologist. The doctor will examine the anus and rectum to determine whether a person has hemorrhoids. Accurate diagnosis is necessary as hemorrhoid symptoms are similar to the symptoms of other anorectal problems, such as fissures, abscesses, warts and polyps.

Your GI will perform a physical exam to look for visible hemorrhoids. A digital rectal exam with a gloved, lubricated finger and an anoscope—a hollow, lighted tube—may be performed to view the rectum.

The GI may advise additional exams to rule out other causes of bleeding, especially in people age 40 or older:

• Colonoscopy. The test involves insertion of a flexible, lighted tube called a colonoscope through the anus, the rectum, and the upper part of the large intestine, called the colon. The colonoscope transmits images of the internal anatomy of the rectum and the entire colon.
• Sigmoidoscopy. Similar to colonoscopy, this procedure uses a shorter tube called a sigmoidoscope and hence it is used to transmit images of the rectum and the sigmoid colon, the lower portion of the colon that empties into the rectum. 
• Barium enema x-ray. This procedure entails insertion of a contrast material such as barium into the colon to make the colon image more visible in x-ray pictures.

Depending upon the procedure(s) chosen, you can code them from CPT® codes (45355-45387).

Note: Your gastroenterologist may also chance upon a hemorrhoid while conducting a totally separate procedure. For example, a patient may report for a screening flex, during which the GI notices internal hemorrhoids. Usually, the physician will not bother about them unless the patient is having problems because of them. 

Rule 3: Check Out How to Code These Hemorrhoid Procedures

The treatments for hemorrhoids — and the codes for hemorrhoid treatment services — differ depending on where they develop. In some cases, hemorrhoids must be treated endoscopically or surgically. These methods shrink and/or destroy the hemorrhoidal vein tissue. The doctor can perform the procedure in the office, at an ambulatory surgery center, or at a hospital outpatient surgery unit. A gastroenterologist or surgeon can perform the various hemorrhoid procedures depending on the required technical aspects.

Ligation: You will see various treatments for internal hemorrhoids, the most common being simple ligature with a rubber band (46221, Hemorrhoidectomy, internal, by rubber band ligation[s]). Using an anoscope, the physician ligates (ties off) the hemorrhoid at its base, which eliminates the blood supply and causes the swollen vein to shrink over time. Over time, the remaining dead tissue and the band will break off and exit with the stool. Because of pain considerations only internal hemorrhoids are banded, and the procedure can be performed in the office.

Important: You should report 46221 only once per session, regardless of how many internal hemorrhoids the physician ligates, which means that you should report a single unit of 46221 irrespective of the fact that the physician bands a single or multiple internal hemorrhoid(s) in the same session.

Sutures: If the physician performs a ligation of the hemorrhoid(s) with a suture, you should report codes 46945 (Hemorrhoidectomy, internal, by ligation other than rubber band; single hemorrhoid column/group) and 46946 (Hemorrhoidectomy, internal, by ligation other than rubber band; 2 or more hemorrhoid columns/groups).

Physicians may sometimes also choose a procedure known as sclerotherapy to reduce blood flow and shrink the hemorrhoid. They will inject a sclerosing solution, such as sodium morrhuate, into the rectal wall’s submucosa under the internal hemorrhoid. You should code such a procedure with 46500 (Injection of sclerosing solution, hemorrhoids). Again, you can report only one unit of 46500 per session, regardless of how many injections or hemorrhoids the physician treats.

You may have also encountered other general procedures for treatment of hemorrhoids. One such procedure is application of heat energy. You should code it with 46930 (Destruction of internal hemorrhoid(s) by thermal energy (e.g., infrared coagulation, cautery, radiofrequency). Other non-conventional procedure is cryosurgery (destruction of hemorrhoids by freezing) where you may use code 46999 (Unlisted procedure, anus).

Rule 4: Don’t Ignore Global Periods

Remember: When coding 46221, this procedure comes with a 10-day global period. So if the patient comes back in during the 10 days following the banding, you won’t get paid for it. General complications in the follow-up period of band ligation include bleeding or severe rectal pain. 

You can file for and receive reimbursement if complications in the global period require an additional trip to the endoscopy center. If you have to go back in and do another scope, you may get paid for that if you use a modifier. Append modifier 78 (Unplanned Return to the Operating/Procedure Room by the Same Physician… During the Postoperative Period) to the procedure code to ensure reimbursement.