Gastroenterology Coding Alert

Dont forget the 90-day global period on 46930.

If your gastroenterologist destroys internal hemorrhoids with heat, youve needed to use a new-for-2009 code. Gastroenterology Coding Alert, Vol. 11, No. 2, alerted you to 46930 (Destruction of internal hemorrhoid[s] by thermal energy [e.g., infrared coagulation, cautery, radiofrequency]).

What may have been a surprise is that the new code treats the procedure as major surgery: 46930 has a 90-day global period. So if your gastroenterologist performs thermal hemorrhoid destruction in stages, youll have to append a modifier or risk losing as much as $189.71.

American Society for Gastrointestinal Endoscopy adviser Glenn D. Littenberg, MD,American Gastroenterology Association adviser Joel V. Brill, MD, and American College of Gastroenterology adviser Daniel C. DeMarco, MD, foresaw this problem. They recommended modifier 76 (Repeat procedure or service by same physician) in the American College of Gastroenterologys 2009 CPT update.

It may be necessary to indicate that a procedure or service was repeated subsequent to the original procedure or service, they wrote. This circumstance may be reported by adding modifier 76 to the repeated procedure/service.

The codes for treating internal hemorrhoids have confused clinicians for years. CPT offers you several hemorrhoid excision codes: 46250-46262 (Hemorrhoidectomy, ...) and 46230 (Excision of external hemorrhoid tags and/or multiple papillae). With multiple codes to describe hemorrhoidectomy and yet another for hemorrhoidopexy -- a related but distinct procedure -- you can easily become overwhelmed when trying to report hemorrhoid removals. However, none of these codes specify that your surgeon only removed internal hemorrhoids. There have been, however, hemorrhoid destruction codes.

And now, you have just one hemorrhoid destruction code thanks to CPT 2009. In January, the AMA deleted 46934-46936 (Destruction of hemorrhoids, any method &) and added 46930.

Be Certain of Your Method

CPT code 46930 is not for incisions or excisions. Deletion of the three codes referenced specifically, incision and excision codes, for the creation of the new code allows more precise coding for nonexcisional procedures, according to the January 2009 Bulletin of the American College of Surgeons. CPT 2009 appends a note to 46930 announcing the demise of the old hemorrhoid destruction codes and referring you to several other codes:

For incision of external thrombosed hemorrhoid(s),use 46083; for destruction of internal hemorrhoids by thermal energy, use 46930; for destruction of hemorrhoid(s) by cryosurgery, use 46999; for excision of hemorrhoid(s), see 46250-46262, 46320; for injection, use 46500; for ligation, see 46221, 46945, 46946; for hemorrhoidopexy, use 46947.

Location: Internal hemorrhoids originate above the dentate line (a mucocutaneous junction that lies about 1 to 1.5 cm above the anal verge). Use of a local anesthetic might be a tipoff that the surgeon treated an external hemorrhoid because internal hemorrhoids can usually be treated without pain. There is no longer a code for heat-destruction of external hemorrhoids.

Edits Target Hemorrhoid Destruction Code, Too

The Correct Coding Initiative hits the new hemorrhoid destruction code 46930 with several bundling edits. You wont be able to report 46930 with anesthesia code 00902,manipulation codes 45900-45915, anorectal exam code 45990, and more. Youll be able to use a modifier to break some of the new 46930 bundles -- for example, the bundle with nerve block codes 64415-64417 and new therapeutic, prophylactic, and diagnostic administration codes 96360-96375.

We were hoping the new hemorrhoid destruction code wouldnt be bundled into a lot of other codes, says Heather Corcoran, coding manager for CGH Billing in Louisville, Ky. This is unfortunate but shouldnt take too much reimbursement away from us.

While doctors usually destroy hemorrhoids in the office, many facilities do these types of cases even though the reimbursement is typically low -- depending upon the CPT code -- if doing so keeps a doctor at the facility.

How to Report 46930 With Other Services

When the physician evaluates a patient with a new problem, you may often report an appropriate-level E/M service and diagnostic scope(s) in addition to hemorrhoid procedures.

For instance: The physician sees a new patient with rectal bleeding. She provides an E/M service that includes a history and exam to determine if the patient has a personal or family history of colon cancer, diverticulitis, or other problems. The physician also performs a diagnostic proctosigmoidoscopy to determine whether a cause other than hemorrhoids is responsible for the bleeding.

The scope reveals no problems in the rectum, sigmoid, or colon. The physician then destroys several hemorrhoids with thermal energy.

In this case you may report an E/M service (such as 99203, Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity) supported by the physicians documentation and scope in addition to the hemorrhoid destruction.

You must append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M service to differentiate it from the inherent E/M component of the other procedures (hemorrhoid destruction, proctosigmoidoscopy) provided on the same date.

Therefore, your claim would read 46930 for the hemorrhoid destruction, 99203-25 (for the E/M service), 45300 (Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).

Facility Procedure Pays Less

When your physician destroys internal hemorrhoids outside the office setting, expect less pay, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C.,and former member of the AMAs CPT Advisory Panel. Medicares 2009 National Physician Fee Schedule values the procedure at $189.71 based on a transitioned nonfacility RVU of 5.26. In a facility setting, the value is $137.41 based on a transitioned facility RVU of 3.81.

Remember: On line 24b of your CMS 1500, report place of service (POS) code 11 when your physician performs the procedure in the office; report code 24 when he works in an ambulatory surgical center.

Know Your Hemorrhoid Dx Codes

There are numerous diagnosis codes for hemorrhoids.

Look for the keyword internal to support 46930:

" 455.0 -- Internal hemorrhoids without mention of complication

" 455.1 -- Internal thrombosed hemorrhoids

" 455.2 -- Internal hemorrhoids with other complication

" 455.3 -- External hemorrhoids without mention of complication

" 455.4 -- External thrombosed hemorrhoids

" 455.5 -- External hemorrhoids with other complication

" 455.6 -- Unspecified hemorrhoids without mention of complication

" 455.7 -- Unspecified thrombosed hemorrhoids

" 455.8 -- Unspecified hemorrhoids with other complication

" 455.9 -- Residual hemorrhoidal skin tags.

Read the proposed decision memo at: www.cms.hhs.gov/mcd/viewdraftdecisionmemo.asp?from2=viewdraftdecisionmemo.asp&id=220&.