Gastroenterology Coding Alert

Question: A physician performed a flexible sigmoidoscopy on a patient in our office, during which the doctor discovered internal hemorrhoids. The physician removed the enlarged blood vessels with rubber-band ligation. Two hemorrhoids were removed using three rubber bands. How should I code this procedure?

Arizona Subscriber Answer: Although gastroenterologists rarely treat hemorrhoids alone, they may discover internal hemorrhoids while performing a sigmoidoscopy, as in the scenario you describe. When this happens, you are correct to code for the hemorrhoidectomy. Keep in mind that no matter how many hemorrhoids are removed during a patient's visit, you can bill only once for a hemorrhoidectomy.
 
For the flexible sigmoidoscopy, use 45330 (Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing). The rubber-band removal of hemorrhoids is coded with 46221 (Hemorrhoidectomy, by simple ligature [e.g. rubber band]). The rules for multiple procedures will apply, so don't forget to append modifier -51 (Multiple procedures) to 46221.
 
Code 46221 will only be accepted once, even if multiple rubber bands are used around one hemorrhoid or if multiple hemorrhoids are removed. CPT Assistant October 1997 states that "Each session of rubber-band ligation, regardless of the number of hemorrhoids, is coded once."
 
In this situation, the gastroenterologist may have chosen to cauterize the hemorrhoid instead. If your doctor decides on this course of action, select the appropriate code depending on the location(s) of the hemorrhoid(s). Here's the breakdown of the cauterization codes:

  Internal: 46934 - Destruction of hemorrhoids, any method; internal
  External: 46935 - Destruction of hemorrhoids, any method; external
  Internal and external: 46936 - Destruction of hemorrhoids, any method; internal and external. Although three codes describe cauterization, gastroenterology coders will usually use the internal hemorrhoid-removal code.  - Clinical and coding expertise for You Be the Coder and Reader Questions provided by Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the CPT advisory panel; and Linda Parks, MA, CPC, CCP, coding and billing coordinator for GI Diagnostic Endoscopy Center in Atlanta.