General Surgery Coding Alert

Are endoscopic and E/M services bundled to hemorrhoidectomy procedures? In some cases they are, but in other cases you may claim them separately, thereby boosting your bottom line. Code E/M Services and Scopes for New Patients When the surgeon evaluates a new patient or an established patient with a new problem, you may often report an appropriate-level E/M service and diagnostic scope(s) in addition to any hemorrhoid procedures, says Kathleen Mueller, RN, CPC, CCS-P, a general surgery coding and reimbursement specialist in Lenzburg, Ill. For instance, the surgeon 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 surgeon also performs a diagnostic proctosigmoidoscopy (45300), sigmoidoscopy (45330) and possibly even colonoscopy (45378) to determine if a cause other than hemorrhoids is responsible for the bleeding. The scopes reveal no problems in the rectum, sigmoid or colon. The surgeon then ligates several hemorrhoids using rubber bands (46221, Hemorrhoidectomy, by simple ligature [e.g., rubber band]). In this case you may report the E/M service supported by the surgeon's documentation (for instance, 99203) and scopes in addition to the hemorrhoidectomy. You must, however, 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 (hemorrhoidectomy, scopes) provided on the same date. Therefore, your claim would read 46221 (for ligature hemorrhoidectomy), 9920x-25 (for the E/M service), 45300 (for proctosigmoidoscopy), 45330 (for sigmoidoscopy) and 45378 (for colonoscopy), Mueller says. Had the patient in this example been established but with new symptoms of bleeding, the above also applies. Don't Bill Scopes for Established Patients Typically, for established patients with known symptoms, you cannot claim scopes or E/M services in addition to rubber banding or other hemorrhoidectomy codes, Mueller says.

For instance, surgeons will often perform an anoscopy (46600) prior to hemorrhoidectomy for an established patient. The National Correct Coding Initiative (NCCI) bundles 46600 to 46221 and considers the anoscopy and any E/M as part of the preprocedure evaluation for the banding (and therefore not separately payable). The NCCI edit coupling 46600 and 46221 includes a "1" status indicator, meaning that if the physician performs an anoscopy for a separate problem (that is, if it is unrelated to the banding procedure), you may report it separately with modifier -59 (Distinct procedural service) appended. For example, for a patient with a history of colon cancer (V10.05), the surgeon may choose to provide a separate scope to check for additional problems beyond hemorrhoids. [...]