Advanced Search

Gastroenterology Coding Alert

Knowing Internal or External Site Takes the Pain Out of Hemorrhoid Coding

Published on Fri Nov 05, 2004

Report 46221 only once for rubber banding regardless of the number of ligations

When you report rubber-band or suture-ligation hemorrhoid removal procedures, make sure you include the appropriate diagnosis code to show medical necessity - or insurers may balk at paying your claims.

Nailing the right hemorrhoid procedure code depends on how well you can navigate the CPT hemorrhoid code categories. Some of the variables you must consider when coding hemorrhoids include the removal method, type of hemorrhoid, and what was done to the hemorrhoid (excision, suture, destruction etc.).

"And then the (code) description itself" can be confusing, says Mike Corasanti, coder at Buffalo Medical Group in New York.

To help gastroenterology coders stay sane, we're presenting an in-depth look at how to report those often-confusing hemorrhoids codes.

Band-Ligation Code Used for Most Removals

In gastro offices, you will mostly see patients with internal rather than external hemorrhoids. (For a thorough description of internal and external hemorrhoids, see "Clip and Save: Use This Hemorrhoid Coding Quick Key" on page 83.)

The gastroenterologist may use a number of methods to remove or reduce the size of the internal hemorrhoid, but the most frequent technique used by most gastroenterologists is rubber-band ligation. "The hemorrhoid removal method we use (most) is rubber banding," Corasanti says.

Example: A primary-care physician (PCP) sees a patient complaining of bright red blood on the toilet paper and in the toilet bowl. After examining the patient with a beveled anoscope, the PCP finds a bleeding internal hemorrhoid and refers the patient to a gastroenterologist.

The gastro performs a flexible sigmoidoscopy to confirm the location of the bleeding, finds the hemorrhoid, and ligates it with a rubber band.

In this scenario, you should:

  • report 45330 (Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) for the sigmoidoscopy

  • report 46221 (Hemorrhoidectomy, by simple ligature [e.g., rubber band]) for the rubber-band ligation

  • prove medical necessity by attaching ICD-9 code 455.2 (Internal hemorrhoids with other complication) to 45330 and 46221.

    Word of Warning: When the gastroenterologist uses rubber-band ligation on a patient with hemorrhoids, report 46221 only once, regardless of how many hemorrhoids have been removed. Insurance companies don't like claims with more than one rubber-band ligation code.

    Gastro May Use Sutures, Other Methods

    While physicians will remove most internal hemorrhoids with rubber-band ligation, there are several other removal methods, says Arlene Soriano, CPC, coder at Atlanta Gastroenterology Associates LLC. Two of the other internal removal methods have specific codes, while other hemorrhoid removal techniques must use the "any method" code.

    Suture ligation - in which the physician isolates the hemorrhoid(s), ties suture material to the base of it, and the hemorrhoid sloughs off as the suture strangulates blood flow - can also be used to treat internal hemorrhoids. Consider this suture-ligation scenario, straight from Soriano.

    Example: A patient reports with bleeding internal hemorrhoids, and the gastroenterologist performs two suture ligations on a pair of internal hemorrhoids. For this encounter, you should:

  • report 46945 (Ligation of internal hemorrhoids; single procedure) for the first suture ligation

  • attach ICD-9 code 455.2 (Internal hemorrhoids with other complication) to 46945.

    Note: If the physician removes more than one hemorrhoid, use 46946 (... multiple procedures) instead of 46945.

    Injection Therapy Has Its Own Code

    A physician can also use sclerotherapy - which involves an injection around the blood vessel to shrink the hemorrhoid - to treat hemorrhoids.

    Example: The gastroenterologist explores a patient's anal canal and identifies hemorrhoid columns. She then injects sclerosing solution into the submucosa of the rectal wall under the hemorrhoidal columns.

    On the claim, you should report 46500 (Injection of sclerosing solution, hemorrhoids) for the procedure.
     
    'Any Methods' Not Coded Clearly

    Sometimes, a physician will treat either internal or external hemorrhoids with a lesser-known therapy such as infrared coagulation, cryosurgery, or laser photography.

    When the gastroenterologist uses a less common hemorrhoid-removal technique, Soriano recommends choosing from the following codes:

  •  46934 - Destruction of hemorrhoids, any method; internal

  •  46935 - ... external

  •  46936 - ... internal and external.

    Before using any of the above codes, be sure to call the payer and make sure it accepts them.

    Prove Strong Medical Necessity

    Soriano warns coders not to report the "any method" (46934, 46935, 46936) or suture-ligation codes (46945, 46946) without showing the payer that the procedure was necessary.

    "CPT codes 46934, 46935, 46936 - and 46945 and 46946 - specify the procedure for a specific type of hemorrhoid; therefore, the diagnosis should support medical necessity for the procedure," she says.

    Gastros Treat External Hemorrhoids Less Often

    While you'll most often see patients with internal hemorrhoids, the physician may occasionally treat a patient with external hemorrhoids. When the gastroenterologist treats a patient with external hemorrhoids, you would most likely report the encounter with either:

  • 46935 (Destruction of hemorrhoids, any method; external) or 46936 (... internal and external) if the gastro cauterized the hemorrhoids

  • 46083 (Incision of thrombosed hemorrhoid, external) if the gastro incised the hemorrhoids.

    • Other Articles in this issue of

    Gastroenterology Coding Alert

    View All