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.

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.

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. But in most cases, "you usually won't get paid for more than rubber banding for an established patient, unless the patient has significant additional problems," Mueller says.

If the surgeon knows that surgery is necessary and chooses to forgo an extensive office examination, which can be painful for the patient, and instead examines the patient in the operating room after anesthesia, you may not report a separate E/M service, says M. Trayser Dunaway, MD, a general surgeon in Camden, S.C. Although the exam may be extensive, the service is not separately identifiable and did not affect the surgeon's decision for surgery (in other words, the service does not meet the requirements for appending modifier -57, Decision for surgery. See "Use -57 for Admission and Same-Day Procedure" on page 70). But you may bill an exam under anesthesia if the surgeon has not yet made a diagnosis. Anal problems can be quite painful, and often the surgeon cannot adequately examine the patient without anesthesia. As long as the documentation states this clearly, you may report an E/M service for such an examination with modifier -23 (Unusual anesthesia) appended.