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 treated the enlarged blood vessels with rubber-band ligation. The physician banded two hemorrhoids using three rubber bands. How should I code this procedure?


Arkansas 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. 

For the flexible sigmoidoscopy, use 45330 (Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]). You should report the rubber-band hemorrhoid removal 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.

Key: Keep in mind that no matter how many hemorrhoids the gastroenterologist removes during a patient's visit, you can bill only once for a hemorrhoid-ectomy. Payers will accept 46221 only once, even if the physician uses multiple rubber bands around one hemorrhoid or removes multiple hemorrhoids. CPT Assistant October 1997 states, "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 hemorrhoid's location(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. Heads up: Although three codes describe cauterization, gastroenterology coders will usually use the internal hemorrhoid removal code.