General Surgery Coding Alert

Don't miss CPT 2010 'either/or' instruction for hemorrhoid location.

You can't choose a hemorrhoidectomy code if you don't know the distinction between internal and external hemorrhoids. Let our experts guide you through the anatomy and coding maze to help you choose the proper code.

"External hemorrhoids occur outside the 'anal verge,' which is at the distal end of the anal canal," explains Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPCP, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program.

Conversely, "internal hemorrhoids are proximal to the anal verge and can be much more difficult to diagnose and treat," she continues.

Vital to identifying different hemorrhoid types is the dentate line.The line is a mucocutaneous junction about a centimeter above the anal verge, and "can be seen separating the anus from the rectum," explains Suzan Berman, CPC, CEMC, CEDC, senior manager of coding and compliance in the surgery and anesthesiology departments at the University of Pittsburgh Medical Center. Internal hemorrhoids occur above the dentate line, and external hemorrhoids occur below the line.

Best bet: Knowing the lingo might help you translate op notes, but having your physician indicate "internal" or "external" will minimize any potential coding errors.

Lack of specific internal hemorrhoid excision codes can be confusing.

For instance: "The only code I can come up with for the excision of one internal hemorrhoid is the unlisted code 46999 (Unlisted procedure, anus)," says Sandra Sickler CPC, CCS, coder with Countryside Surgery Center in Clearwater, Fla.

Solution: By adding the following text note, CPT 2010 allows you to use certain codes for internal and/or external hemorrhoids: "For excision of internal and/or external hemorrhoid(s), see 46250-46262, 46320." That means you can use 46255 (Hemorrhoidectomy, internal and external, single column/group) for the excision of one internal hemorrhoid (or 46260 [... 2 or more columns/groups] for excision of multiple internal hemorrhoids), according to Bucknam.

You might report 46945 (Hemorrhoidectomy, internal, by ligation other than rubber band; single hemorrhoid column/group)or 46946 (... 2 or more hemorrhoid columns/groups) for certain internal hemorrhoid excisions, according to Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta. Known as "transfixion suture excision" the surgeon places a crisscross stitch and ties off the base of the hemorrhoid with the suture (ligation) to control bleeding. Then the surgeon excises and removes the remaining hemorrhoid.

Another problem: Your surgeon might excise a thrombosed internal hemorrhoid, but 46320 (Excision of thrombosed hemorrhoid, external) describes an external hemorrhoid procedure. Based on the new text note for internal and/or external codes, you can use 46320 for internal hemorrhoids, Bucknam says.

Follow 'External' Rules for Proper Code Choice Although the new text note for internal and/or external codes might seem to allow 46255 for a single external hemorrhoid, a separate text note following 46250 directs, "for hemorrhoidectomy, external, single column/group, use 46999."

Similarly, for excision of multiple external hemorrhoids you should use the most specific code 46250 (Hemorrhoidectomy, external, 2 or more columns/groups) rather than 46260.

Your surgeon may excise a "mixed" or confluent hemorrhoid that begins above the dentate line and extends below it. These hemorrhoids demonstrate attributes of both an external and internal hemorrhoid. In these cases, you should not select separate internal and external excision codes.

Instead: You should use 46255 or 46260, as appropriate, based on the number of columns/groups.