General Surgery Coding Alert

Ignore CPT 2010 changes and risk choosing the wrong code.

With a  (revised) symbol marking most relevant hemorrhoidectomy codes and several new text notes in CPT 2010, you need to rethink your coding for these procedures this year.

Implement the following four tips to help you choose the proper hemorrhoidectomy code and make sure you capture all the pay your practice deserves.

General surgeons have lots of ways to treat hemorrhoids, and one thing that hasn't changed in CPT 2010 is that you need to consider the method when you select the code.

Capture ligature services: CPT provides the following three codes for hemorrhoid ligation, which involves tying off the blood vessel to restrict blood flow:

• 46221 -- Hemorrhoidectomy, internal, by rubber band ligation(s)

• 46945 -- ... by ligation other than rubber band; single hemorrhoid column/group

• 46946 -- ... by ligation other than rubber band; 2 or more hemorrhoid columns/groups.

During a ligation procedure, the surgeon "ties off" (ligates) the hemorrhoid at its base, which cuts off its blood supply and causes it to shrink over time. Banding internal hemorrhoids is a more common treatment than excision, according to Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta. Know excision codes: CPT provides the following codes for hemorrhoid excision (excluding codes for hemorrhoidectomy with other procedures/conditions such as thrombosis, fissurectomy, or fistulectomy):

• 46250 -- Hemorrhoidectomy, external, 2 or more columns/groups

• 46255 -- Hemorrhoidectomy, internal and external, single column/group

• 46260 -- ... 2 or more columns/groups.

Check out other methods: If the physician injects solution to cause the hemorrhoid to harden and shrivel, report 46500 (Injection of sclerosing solution, hemorrhoids). For thermal destruction, list 46930 (Destruction of internal hemorrhoid[s] by thermal energy [e.g., infrared coagulation, cautery, radiofrequency]). For destruction by cryosurgery, report 46999 (Unlisted procedure, anus).

Hemorrhoidopexy is different: 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 procedure for prolapse and hemorrhoids (PPH), the surgeon performs a progressive anal dilation, inserts a circular anoscope, and 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).

Sometimes a hemorrhoid forms a thrombosis, or clot. If the surgeon treats a thrombosed hemorrhoid, you have two code choices:

• 46083 -- Incision of thrombosed hemorrhoid, external Use this code if the surgeon performs an incision and drainage (I&D) to remove the clot only.

• 46320 -- Excision of thrombosed hemorrhoid, external Don't use other excision codes described in Tip 1 if the hemorrhoid is thrombosed -- use this code instead.

Tip 3: Know Internal/External Distinction

Surgical notes for hemorrhoidectomy procedures might mention "anal verge" and "denate line" to describe whether the hemorrhoid is internal or external. But some coders might not have the clinical knowledge to identify different hemorrhoid types from encounter notes, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program. To save time and money on your hemorrhoidectomy claims, the surgeon should specify "internal" or "external" in the documentation, Bucknam recommends.

Here's why: Many CPT hemorrhoid codes indicate "internal," "external," or "internal and external" in the code definition -- you need this information to select the proper code.

Historically, coders have had problems when the surgical procedure and the internal/external designations don't match up. But CPT 2010 provides some new direction in these matters. Look to "Navigate Your Way to Proper Internal/External Hemorrhoid Coding" on page 19 of this issue to learn more about internal/external hemorrhoid classification and CPT coding instruction.

Tip 4: Count Columns to Narrow Selection

Past CPT code definitions referred to "complete," "simple," and "complex/extensive" hemorrhoidectomies (46250-46262) and "single" or "multiple" procedures (46945-46946).

CPT 2010 clarifies and standardizes these code definitions by referring to "single hemorrhoid column/group" or "2 or more hemorrhoid columns/groups." This change accounts for the 􀀘 (revised) symbol marking many hemorrhoidectomy codes in CPT 2010.

Understand columns: Per CPT guidelines, you can identify an anal column at three major areas in the anal canal: right posterior (1 o'clock), right anterior (5 o'clock), and left lateral (9 o'clock) positions of the anus. The physician should identify the number of columns/groups involved in any hemorrhoid procedure.

Example: If the surgeon treats an internal hemorrhoid at left lateral and an external hemorrhoid at right posterior, then you would report 46260, because the hemorrhoids are in different columns.

The change to emphasize columns/groups in code definitions means that in most cases, you may report only one code to describe hemorrhoid removal -- even if the surgeon removes multiple hemorrhoids during the session.

Exception: Unlike other methods, excision or 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.