General Surgery Coding Alert

Location and count are key to correctly coding hemorrhoids.

When the surgeon removes one or more hemorrhoids for patients, the procedure can pose multiple coding challenges for coders specializing in general surgery.

Why? Initially, selecting from a variety of specific codes for hemorrhoid removal can be complex. Furthermore, if multiple hemorrhoids are excised, or if several procedures are carried out, as the coder, you will need to understand which procedures encompass multiple excisions and which are combined. The coder must decide which procedures can be billed separately.

Definition: Hemorrhoids refer to the veins in the rectum and/or anus that have become enlarged due to dilation, a condition known as varicosity. When the hemorrhoid forms above the dentate line, which is a junction between the mucous membrane and skin approximately 1 to 1.5 cm above the edge of the anus, it is categorized as an internal hemorrhoid. Internal hemorrhoids are treatable with over-the-counter medications, but if persistent they may require surgical intervention.

Pocket These Fundamentals on Internal Hemorrhoid Removal

By far, the most common hemorrhoid removal procedure is rubber band ligation using code 46221 (Hemorrhoidectomy, internal, by rubber band ligation(s)). “Hemorrhoid banding is a simple procedure that can be performed in the office. Only more invasive procedures require a patient to be treated at an [ambulatory surgery center] (ASC) or a hospital [operating room] (OR),” according to Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, product manager, MRO, in Philadelphia.

CPT^® also describes other means, aside from excision, of removing internal hemorrhoids. Code 46500 (Injection of sclerosing solution, hemorrhoids) involves administering an 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 46930 (Destruction of internal hemorrhoid(s) by thermal energy (eg, infrared coagulation, cautery, radiofrequency)). Each of these procedures is performed far less frequently than banding.

Understand the Nuances of External Hemorrhoid Removal

External hemorrhoids, originate below the dentate line. Patients may be unaware they have an external hemorrhoid unless and until they develop a blood clot, causing a thrombosed external hemorrhoid. When this occurs, 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 (Excision of thrombosed hemorrhoid, external). 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 (Excision of single external papilla or tag, anus) would be billed.

Note: Excision of multiple skin tags and/or external hemorrhoids is coded as 46230 (Excision of multiple external papillae or tags, anus).

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, 2 or more columns/groups) should be coded.

“Note that if a hemorrhoid or series of hemorrhoids are described as internal/external, use the external codes for their removal unless the procedure explicitly describes an internal removal. An internal/external hemorrhoid is one that originates above the dentate line but terminates externally,” says Joy.

Critical information: Codes 46255 (Hemorrhoidectomy, internal and external, single column/group) and 46260 (Hemorrhoidectomy, internal and external, 2 or more columns/groups) are used when surgeons excise both internal and external hemorrhoids. During both of these procedures, 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 completely.

Know the Facts on 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. For this procedure, you will use code 46080 (Sphincterotomy, anal, division of sphincter (separate procedure)).

In some cases, when performing an internal and external hemorrhoidectomy, the surgeon may opt for a fissurectomy. This procedure, which also includes the excision of the internal and/or external hemorrhoids, is coded as either 46257 (Hemorrhoidectomy, internal and external, single column/ group; with fissurectomy) or 46261 (Hemorrhoidectomy, internal and external, 2 or more columns/groups; with fissurectomy) depending on whether the location is internal or external.

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 into the skin. In such cases, the surgeon may perform a fistulectomy to remove the roof of the fistula as well as the patient’s internal and/or external hemorrhoids. If a fissure is also present, this would be treated during that surgery as well. To code the hemorrhoidectomy with or without fistulectomy, you would choose either 46258 (Hemorrhoidectomy, internal and external, single column/group; with fistulectomy, including fissurectomy, when performed) or 46262 (Hemorrhoidectomy, internal and external, 2 or more columns/groups; with fistulectomy, including fissurectomy, when performed) based on the number of columns or groups of hemorrhoids being removed.