General Surgery Coding Alert

Don't fall victim to the 46934 coding pitfall, especially in 2009.

When it comes to choosing a code for the excision of internal hemorrhoids, CPT leaves you with more questions than answers. There is no code specifically for this type of hemorrhoid excision.

You might be tempted to report 46934 (Destruction of hemorrhoids, any method; internal) when your general surgeon excises internal hemorrhoids. However, experts advise against that code. Plus, as of Jan. 1, 46934 is a deleted code. So which code should you report to make sure your surgeon gets paid for this procedure?

CPT Doesn't Offer a Straight Answer

When you see that your surgeon performed a hemorrhoid procedure, you-ll need to dig into his operative report to find out the treatment method and the location of the hemorrhoids. "The coder needs to know how the hemorrhoid was dealt with," says Joseph A. Lamm, office manager for Stark County Surgeons in Massillon, Ohio. "This information immediately narrows the possible codes, based on excision, destruction, sclerosing, or suture. Then the coder would need to know internal, external, or both."

The problem: CPT offers you several hemorrhoid excision codes. However, none of them specify that your surgeon only removed internal hemorrhoids.For an excision of an external hemorrhoid, you-ll report 46230 (Excision of external hemorrhoid tags and/or multiple papillae) or 46320 (Enucleation or excision of external thrombotic hemorrhoid). If the surgeon removes non-thrombosed, external hemorrhoids via excision, you should select 46250 (Hemorrhoid-ectomy, external, complete).

When your surgeon excises both external and internal hemorrhoids during the same session, you would use 46255 (Hemorrhoidectomy, internal and external, simple) or 46260 (Hemorrhoidectomy, internal and external, complex or extensive).

Bottom line: There are specific codes for external excision and the excision of both internal and external hemorrhoids, but there is not a code for internal alone.

Watch for: Your surgeon's documentation should explicitly state the location of the hemorrhoids he treats. If the documentation is not clear, be sure to ask the surgeon for details and get the information in the chart. You can't select a proper code without this knowledge -- and, "as auditors love to say, -If it isn't documented, it didn't happen,-" Lamm stresses.

"The state of the hemorrhoid (thrombosed or not) along with the action being taken and the location must all be illustrated," agrees Suzan Berman-Hvizdash, CPC, CPC-E/M, CPC-EDS, physician educator for the University of Pittsburgh and past member of the American Academy of Professional Coders National Advisory Board. "Communication between the coder and the doctor can come through the documentation. There are many techniques for hemorrhoid care and the more information that goes between the coder and the MD the better the code choice will be."

Don't Count on 46930

"With regard to code 46934, I do not believe that this was ever the right code for excision of hemorrhoids," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-OBGYN, CPC-CARDIO, manager of compliance education for the University of Washington Physicians and Children's University Medical Group Compliance Program "This code was for destruction of hemorrhoids."

CPT replaces 46934 with a new code: 46930 (Destruction of internal hemorrhoid[s] by thermal energy [eg, infrared coagulation, cautery, radiofrequency]).

Watch out: "The new code 46930 is only for thermal destruction and only for internal hemorrhoids," Bucknam warns. You cannot use 46930 for the excision of internal hemorrhoids, she adds.

Option 1: You can report an excision of internal hemorrhoids using 46255 with modifier 52 (Reduced services) appended, Bucknam says. There is very little difference in the work RVUs for 46255 and 46230, she says, "so I wouldn't reduce the fee; just add modifier 52 to indicate that only internal hemorrhoids were treated."

Option 2: "Alternatively, the only choice would be the unlisted code 46999 (Unlisted procedure, anus)," says Bucknam. "It might be that with the deletion of 46934 our best advice is to use the unlisted code."

Option 3: Codes 46945 (Ligation of internal hemorrhoids; single procedure) or 46946 (- multiple procedures) may be the correct codes to look at, depending on your surgeon's documentation. "For an excision or removal of an internal hemorrhoid, I would use CPT 46945 or 46946," says Sandra Jongebreur, CPC-GENSG, CPC, CPC-H, PCS, FCS, billing manager for Raafat Z. Abdel-Misih, MD and Joseph J. Bennett, MD in Wilmington, Del. "This procedure is more commonly known as a transfixion suture excision (a crisscross stitch placed so as to control bleeding from a tissue surface or small vessel when it is tied). The physician sutures/ligates the base of the hemorrhoid. Then the remaining hemorrhoid is excised and removed," Jongebreur explains.

Note: This is unlike the procedure that you report using 46221 (Hemorrhoidectomy, by simple ligature [e.g., rubber band]). You-ll use 46221 when your surgeon ligated or banded the hemorrhoid at base of hemorrhoid by rubber ring banding, expecting the hemorrhoid to shrink over time.

The two most common ways of treating internal hemorrhoids are by ligation/banding, which you-ll use 46221 for, and 46945, which you-ll use when the surgeon sutured/ligated the hemorrhoid at the base and removed excess tissue, Jongebreur says.

"It is difficult to make this coding decision without seeing exactly what the surgeon did," Bucknam emphasizes. "If the ligation with excision was what the surgeon described in his note, that would certainly be the right way to code the service. If he described an actual resection of the rectal mucosa, then my suggestion with modifier 52 would apply best," she adds.

Key: You will need to check with your individual payers to determine which coding option they prefer you use when your general surgeon excises only internal hemorrhoids.

Good tip: "The best advice I can give coders is to make up a -cheat sheet- for hemorrhoidectomies (actually for all the surgeries that they code for)," Lamm suggests. "This way all of the possible codes are together on one page. This is much easier, and much quicker, than using their CPT book. They can also put on this sheet the most commonly used diagnosis codes for quick reference."