Gastroenterology Coding Alert

After selecting the appropriate hemorrhoid procedure performed, consider whether the hemorrhoid code is a component of the primary procedure that the gastroenterologist performed. In the above example of the gastroenterologist who performs a colonoscopy, neither banding nor cauterizations are included in the colonoscopy codes. Therefore, both procedures may be reported (see using modifier -51, below).

However, the Correct Coding Initiative bundles rubber-band ligation code 46221 with three anoscopy codes: 46600 (Anoscopy; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), 46604 ( with dilation [e.g., balloon, guide wire, bougie) and 46606 ( with biopsy, single or multiple), Bahm notes. Therefore, you cannot report both the banding and the anoscopy.

You should bill only the higher-valued procedure in this case, experts recommend. The 2002 National Physician Fee Schedule Relative Value File assigns 3.96 nonfacility relative value units (RVUs) for 46221, which is higher than the nonfacility RVUs for the anoscopy codes. (Code 46600 contains 1.36 nonfacility RVUs. Anoscopy with dilation code 46604 is valued at 2.39 nonfacility RVUs. Code 46606 has 1.75 nonfacility RVUs.) So, report the rubber-band ligation only.

For endoscopic procedures, such as colonoscopies and flexible sigmoidoscopies, which are not bundled with hemorrhoid removal codes, you should report both the endoscopic procedure and the hemorrhoidectomy and append modifier -51 (Multiple procedures) to the lower-valued code. "Without the modifier, many payers may bundle the procedures and deny payment," Bahm warns. Multiple-procedure rules apply, so the payer will reimburse the primary procedure at 100 percent and subsequent procedures at 50 percent.

All colonoscopy codes have a higher value than the banding codes. Therefore, when these procedures are performed together, you should always report the colonoscopy and then the banding.

For instance, suppose a gastroenterologist ablates a polyp during a colonoscopy and then ligates a hemorrhoid using rubber bands. For the polyp ablation, assign 45383 (Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor[s], polyp[s], or other lesion[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique), which has 8.75 facility RVUs. For the banding, report 46221 (3.28 facility RVUs).

List the higher-valued procedure, the colonoscopy (45383), first. Next, report the lower-valued procedure, the banding (46221), appended with modifier -51 to indicate that the rubber-band ligation is performed at the same session by the same provider. The insurer should reimburse the colonoscopy at 100 percent and the banding at 50 percent.

Remember to look at the appropriate place-of-service value. In the above example, the facility RVUs were considered because gastroenterologists usually perform colonoscopies in a facility setting, rather than an office. However, for the anoscopy example, we cited the nonfacility RVUs because the procedure is often performed in the office.

Regardless of location, the cauterization codes are valued much higher than the banding codes. Therefore, in some situations it is appropriate to report the cauterization code first.

For instance, a physician performs a diagnostic sigmoidoscopy and uses a probe to cauterize an internal hemorrhoid. The sigmoidoscopy code 45330 (Sigmoi-doscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) is valued at 1.54 facility RVUs. The hemorrhoid code 46934 consists of 7.54 facility RVUs. Assign the hemorrhoid code first (46934), followed by the flex sig code (45330), appended with modifier -51. Reimbursement will be 100 percent for the cauterization and 50 percent for the sigmoidoscopy.

For a complete list of appropriate reimbursement and coding scenarios, see the chart below.

When a patient requires treatment after hemorrhoid removal, coding depends on the global period for each code. Codes 46221 and 46935 have 10-day global periods, whereas 46934 and 46936 have 90-day global periods. Any in-office care that relates to the hemorrhoid removal is included in the procedure fee and cannot be billed separately.

E/M services that are unrelated to the hemorrhoi-dectomy that are performed during the global period are separately reimbursable. Modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period) must be appended to the appropriate E/M service (e.g., 99211-99215, Established patient office visit). Make sure the documentation shows that the patient was treated for a reason unrelated to the hemorrhoid treatment.

Some patients may have discomfort or bleeding from the rubber bands, in which case another endoscopy is required to remove them. Related procedures that require a return trip to the operating room are separately reimbursable with modifier -78 (Return to the operating room for a related procedure during the postoperative period).

For instance, consider a gastroenterologist who performs a flex sig with control of bleeding to remove rubber bands within the global period of a rubber-band ligation. The physician should report 45334 ( with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]) appended with modifier -78. No code describes the removal of the bands, so experts recommend reporting the sigmoidoscopy only.