General Surgery Coding Alert

The removal of one or more hemorrhoids can lead to several coding dilemmas for general surgery coders. First, it may be difficult to choose from several specific hemorrhoid removal codes. Second, if more than one hemorrhoid is removed, or if more than one procedure is performed, the coder must know which procedures include multiple removals and which are bundled. Third, if the surgeon performs a significant, separately identifiable evaluation and management (E/M) service, or a scope of some kind or both in addition to the removal, the coder must decide which procedures can be billed seperately.

Hemorrhoids are veins in the anus and/or rectum that have dilated, resulting in an increased size (varicosity). If the hemorrhoid originates above the dentate line (a mucocutaneous junction that lies about 1 to 1.5 cm above the anal verge), it is classified as an internal hemorrhoid. Internal hemorrhoids are treatable with over-the-counter medications, but if persistent they may require surgical intervention. By far the most common hemorrhoid removal procedure is rubber band ligature (46221, hemorrhoidectomy, by simple ligature [e.g., rubber band]) notes M. Trayser Dunaway, MD, a general surgeon in Camden, S.C.

CPT also describes other means, aside from excision, of removing internal hemorrhoids. Code 46500 involves sclerotherapy the injection of sclerosing solution into the submucosa of the rectal wall under the hemorrhoid columns. Other methods of destroying hemorrhoids, which include using electrical current or infrared radiation, are coded 46934 (destruction of hemorrhoids, any method; internal). Each of these procedures is performed far less frequently than banding.

Note: Code 46935 describes destruction of external hemorrhoids by any method; 46936 describes destruction of internal and external hemorrhoids by any method. Like 46934, these codes are rarely used.

External hemorrhoids, unlike internal hemorrhoids, originate below the dentate line. Patients may be unaware they have an external hemorrhoid unless and until they develop a blood clot (thrombosed external hemorrhoid). When this occurs, Dunaway says, the surgeon has three options: (1) do nothing, and eventually the thrombosed hemorrhoid will become a skin tag; (2) perform incision and drainage (I&D) to remove the clot only; or (3) excise the vessel and the clot simultaneously.

The second and third options involve immediate procedures. For I&D, code 46083 (incision of thrombosed hemorrhoid, external); if the clot and hemorrhoid are excised, use 46320 (enucleation or excision of external thrombotic hemorrhoid). The first option, however, may also involve a procedure at a later date if the patient and surgeon determine that the skin tags (which contain no blood vessels) need to be removed. In that case, 46220 (papillectomy or excision of single tag, anus [separate procedure]) would be billed.

Note: Excision of multiple papillae (sentinel piles) and/or external hemorrhoid tags (not to be confused with anal skin tags) is coded 46230.

If they are large enough, non-thrombosed external hemorrhoids may also be excised, often at the same time as internal hemorrhoids. CPT lists several codes for these procedures that vary depending on whether the procedure was simple or complex, and whether other procedures (fissurectomy or fistulectomy) were also performed.

If the surgeon removes only external hemorrhoids, including multiple external hemorrhoids that do not contain a blood clot, 46250 (hemorrhoidectomy, external; complete) should be coded. This code should not be confused with 46320, which is used for a single, thrombosed hemorrhoid.

Codes 46255 (hemorrhoidectomy, internal and external; simple) and 46260 (...complex or extensive) are used when surgeons excise both internal and external hemorrhoids. Medicodes Coders Desk Reference describes 46255 and 46260 as nearly identical, although apparently 46255 involves a single column and 46260 involves multiple columns. In either procedure, the surgeon explores the anal canal, identifies the hemorrhoid column(s), makes an incision in the rectal mucosa around the hemorrhoids, dissects the lesions from the underlying sphincter muscles and removes them.

Based on the number and size of hemorrhoids removed, the physician must make a subjective judgment whether to choose 46255 or 46260, Dunaway says.

Note: When selecting 46260, the determining factors must be documented in the operative report.

Sphincterotomy, Fissurectomy and Fistulectomy

On occasion, the surgeon also may treat a fissure a chronic crack in the anoderm that splits the mucosa and exposes the sphincter muscle associated with internal or external hemorrhoids, usually by performing a lateral internal sphincterotomy (46080, sphincterotomy, anal, division of sphincter [separate procedure]). As a separate procedure, 46080 cannot be billed if another related procedure, such as hemorrhoidectomy, is performed. For example, 46080 is bundled with 46221 in the national Correct Coding Initiative.

In some cases, when performing internal and external hemorroidectomy, the surgeon may opt for a fissurectomy. This procedure, which also includes the excision of the internal and external hemorrhoids, is coded either 46257 (hemorrhoidectomy, internal and external, simple, with fissurectomy) or 46261 (hemorrhoidectomy, internal and external, complex or extensive, with fissurectomy).

Other times, the surgeon may need to perform an even more extensive procedure that involves excising an anal fistula. Such fistulae, or passageways, may form when a perirectal abscess caused by an infected crypt (or blind pit) drains to the skin. In such cases, the surgeon may excise the fistula fistulectomy or remove the roof of the fistula fistulotomy as well as the patients internal and external hemorrhoids. If a fissure is present, it too may be treated. As with the hemorrhoidectomy on its own and with fissurectomy, two codes are available for this procedure: 46258 (hemorrhoidectomy, internal and external, simple, with fistulectomy, with or without fissurectomy) and 46262 (hemorrhoidectomy, internal and external, complex or extensive, with fistulectomy, with or without fissurectomy).

Correctly Code Multiple Removals, E/M and Scopes

Patients who require simple hemorrhoid removal by ligature may have more than one hemorrhoid removed during the same session. If multiple hemorrhoids are present, the surgeon may band one or two and schedule the patient for another banding at a subsequent date.

Although some carriers may pay for each hemorrhoid removed, most will not. CPTs listing for 46221 references the October 1997 CPT Assistant, which instructs physicians to bill 46221 only once per operative session regardless of how many hemorrhoids are banded at that time.

Unlike banding, the excision and I&D of a thrombosed hemorrhoid describes only one hemorrhoidectomy. If the surgeon removes one or more additional thrombosed hemorrhoids, these should be billed separately. Carriers may not pay for more than one removal during the same operative session, however.

If multiple hemorrhoids are destroyed by any other method, only one code (either 46934, 46935 or 46936) should be billed, because the code descriptors for these procedures specifically refer to hemorrhoids (plural).

More complex hemorrhoidectomies also typically include multiple excisions. The CPT code descriptors for many procedures, including 46255, 46257, 46258, 46260, 46261 and 46262, mention more than one removal. The code descriptor for 46250 is more vague, but Medicodes Coders Desk Reference confirms that it is meant to include one or more hemorrhoids.

When a surgeon removes one or more hemorrhoids, he or she may also perform an E/M service and scope the patient. Payment for these procedures depends on the status of the patient (new or established) and on the documented level of the services provided.

For example, says Elaine Elliott, CPC, a practice coder with Treasure Coast Surgical Group, an eight-physician practice in Stuart, Fla., the surgeon sees a new patient with rectal bleeding and performs a full workup that includes history and examination to determine if the patient has a personal or family history of colon cancer, diverticulitis or other problems. A diagnostic proctosigmoidoscopy (45300), sigmoidoscopy (45330) or even colonoscopy (45378) is also performed to rule out a cause for bleeding other than hemorrhoids. The scope finds nothing in the rectum, sigmoid or entire colon, and two hemorrhoids are ligated using rubber bands.

In this case or even if the patient is established but has a new problem the surgeon should bill the hemorrhoidectomy (46221), the appropriate level E/M (9920x-25) and the scope, Elliott says.

For a new patient or an established patient with a new problem, performing an evaluation before undertaking a procedure is sound medical practice, but modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day as the procedure or other service) must be appended to the E/M service.

If the patient is new, some carriers may not pay for all three services, Elliott warns. If the carrier will pay for only two procedures, she recommends billing for the hemorrhoid banding and the E/M. After all, she reasons, in this case the scope can be considered part of the E/M.

Billing Examinations

For established patients the surgeon will likely perform an anoscopy (46600) and the hemorrhoidectomy. The anoscopy and any E/M are considered part of the preprocedure evaluation for the banding, and are bundled with 46221 in the national Correct Coding Initiative.

Note: If the anoscopy is performed for another problem, it may be billed the CCI edit includes a 1 indicator, which means the code may be billed separately under certain conditions, including a separate problem.

For an established patient, you will seldom get [reimbursed for] more than rubber banding, unless he or she has a significant other problem, notes Elliott. Occasionally, she says, this does occur. She cites a case where a commercial carrier, after review, paid for both a scope and hemorrhoid removal: Because of the patients personal history of colon cancer (V10.05), the doctor would have been negligent not to evaluate.

With extensive procedures, such as hemorrhoidectomies that include fissure treatment, some surgeons may skip a thorough (and potentially painful) office examination and instead examine the patient just enough to identify the fissure and determine that surgical treatment is required, Dunaway says. When the patient is anesthetized for surgery, the surgeon would then perform a thorough examination on a comfortable patient.

Although this examination is significant, it is not billable, because it is not separately identifiable and did not lead to the decision to perform surgery. The first exam should be billed, however, but because it was cursory it can be considered only a low-level E/M service.