General Surgery Coding Alert

 Location matters more than number for all removal methods

With multiple codes to describe hemorrhoidectomy and yet another for hemorrhoidopexy -- a closely related but distinct procedure -- you can easily become overwhelmed when trying to report hemorrhoid removal procedures. Fortunately, you can cut through the confusion by following these four tips.

Tip 1: Narrow Selection by Location

Before choosing a hemorrhoidectomy code, you must know whether the hemorrhoids the surgeon removed were internal, external or a combination of both types.
 
Internal hemorrhoids are those that originate above the dentate line (a mucocutaneous junction that lies about 1 to 1.5 cm above the anal verge). Codes that may apply for internal hemorrhoid removal include:

 - 46221 -- Hemorrhoidectomy, by simple ligature (e.g., rubber band).
 
This is by far the most common hemorrhoid removal procedure. During the treatment, the surgeon -ties off- (ligates) the hemorrhoid at its base, which cuts off its blood supply and causes it to shrink over time.

 - 46500 -- Injection of sclerosing solution, hemorrhoids.

In this procedure, the surgeon injects a sclerosing solution into the submucosa of the rectal wall under the hemorrhoid. Once again, this reduces blood flow to the area and causes the hemorrhoid to shrink.

 - 46934 -- Destruction of hemorrhoids, any method; internal.
 
This is a -not otherwise specified- code to describe any method of destruction other than ligature or sclerosing solution. Such methods could include using electrical current or infrared radiation, for instance.
 
External hemorrhoids originate below the dentate line and can call for a greater variety of treatment options (see Tip 2 below).
 
Watch for: Your surgeon's documentation should explicitly state the location of the hemorrhoids he treats. If the documentation is not clear, be sure to ask the surgeon for details. You can't select a proper code without this knowledge.
 
Tip: -If the surgeon used a local anesthetic, that might be a tip-off that he treated an external hemorrhoid because internal hemorrhoids can usually be treated without pain,- says M. Trayser Dunaway, MD, FACS, CSP, CHCO, CHCC, a surgeon, physician and coding educator, and healthcare consultant in Camden, S.C.

Tip 2: Look for Evidence of Thrombosis

If the surgeon treats external hemorrhoids, you must consider whether the hemorrhoids are thrombosed (clotted), Dunaway says. When treating a thrombosed external hemorrhoid, the surgeon has three options:
 
1. Wait until the hemorrhoid develops into a skin tag and then, if appropriate, remove it. In this case, if the surgeon does remove the skin tag, you should report either 46220 (Papillectomy or excision of single tag, anus [separate procedure]) or 46230 (Excision of external hemorrhoid tags and/or multiple papillae), depending on whether the surgeon removes a single or multiple tag(s).
 
2. Perform an incision and drainage (I&D) to remove the clot only. In this circumstance, you would report 46083 (Incision of thrombosed hemorrhoid, external).
 
3. Perform an excision to obliterate the clot and hemorrhoid at the same time. The best code to describe this procedure is 46320 (Enucleation or excision of external thrombotic hemorrhoid).
 
Tip: If a patient presents with symptoms of -pain,- you are generally dealing with a thrombosed hemorrhoid, Dunaway says.
 
Non-thrombosed options: If the surgeon removes non-thrombosed, external hemorrhoids via excision, you should select 46250 (Hemorrhoidectomy, external, complete).
 
For removal of external hemorrhoids by any method other than excision, you should choose 46935 (Destruction of hemorrhoids, any method; external). This code, like 46934, can include electrical current, infrared radiation, and other methods.

Tip 3: Use Dedicated Codes for -Combo- Removals

When the surgeon excises both external and internal hemorrhoids during the same session, you won't select one of each code from the external and internal excision codes.
 
Instead: You should use 46255 (Hemorrhoidectomy, internal and external, simple) or 46260 (Hemorrhoidectomy, internal and external, complex or extensive).
 
Based on the number and size of hemorrhoids removed, the physician must make a subjective judgment to choose 46255 or 46260, Dunaway says. To support your coding claim, you must be sure that the physician's documentation justifies the selection of 46260 by noting the determining factors.
 
Non-excision option: CPT also provides 46936 (Destruction of hemorrhoids, any method; internal and external) to describe destruction of internal and external hemorrhoids by any method other than excision.

Tip 4: Report a Single Unit, in Most Cases

In all but a few cases, you will only report a single unit of a single code to describe hemorrhoid removal -- even if the surgeon removes multiple hemorrhoids during the same session, says Suzan Hvizdash, CPC, CPC-EMS, CPC-EDS, physician educator for the University of Pittsburgh and American Academy of Professional Coders National Advisory Board Member.
 
Examples: The descriptors for both 46500 and 46934 specify -hemorrhoids- (plural). Therefore, you should report these codes only once per session, regardless of how many hemorrhoids the surgeon treats. Similarly, 46250 can describe removal of a single or several hemorrhoids.
 
Codes 46255, 46260 and 46936 likewise apply to single or multiple removals during the same operative session. In other words, if the surgeon excises two internal hemorrhoids and one external hemorrhoid during the same operation, you should report only a single unit of 46255.
 
Exception: Unlike other methods, the excision and I&D of a thrombosed hemorrhoid (46083, 46320) describes only one removal. If the surgeon removes one or more additional thrombosed hemorrhoids, you should bill them separately, using 46083 or 46320, as appropriate.

Bonus Tip: Distinguish Hemorrhoidopexy/Hemorrhoidectomy

You should be careful not to confuse hemorrhoidopexy -- an alternative method for treating prolapsing internal hemorrhoids -- with hemorrhoidectomy as described by the methods discussed above.
 
During hemorrhoidopexy, also called PPH (procedure for prolapse and hemorrhoids), the surgeon performs a progressive anal dilation, inserts a circular anoscope into the anus, then uses a stapling technique to repair the prolapse.
 
The appropriate code to report this technique is 46947 (Hemorrhoidopexy [e.g., for prolapsing internal hemorrhoids] by stapling).
 
What to look for: Hemorrhoidopexy does not require that the surgeon remove the hemorrhoidal tissue, as in a typical hemorrhoidectomy. Therefore, coders should be sure to read operative notes carefully to be sure the surgeon specifies -stapling- rather than -excision- of the hemorrhoid(s).
 
Be sure you meet the requirements: The most important factor when reporting 46947 is to prove that the physician tried more conservative approaches first. In addition, Medicare won't cover PPH unless the prolapsed hemorrhoids are at least Grade III (that is, the hemorrhoid protrudes from the anus during a bowel movement, but can be pushed back into the anus), says Lori Owens with Ohio Valley Surgical Specialists in Owensboro, Ky.