General Surgery Coding Alert

Can you easily distinguish among the nine CPT codes (46221-46262) that describe hemorrhoidectomy? Just five expert tips can help you decide which code to choose, when to report a single unit or multiple units of a given code, and how to report treatments not described by 46221-46262.

1. Determine Hemorrhoid Location

When coding for hemorrhoid procedures, the first thing you'll want to do is classify the type of hemorrhoid(s) involved.
 
"Hemorrhoids are either internal or external," says M. Trayser Dunaway, MD, FACS, a general surgeon in Camden, S.C. "In some cases, the surgeon may deal with both kinds during the same session. But whatever the circumstances, the codes you'll report are directly related to the location of hemorrhoids involved."
 
An internal hemorrhoid originates above the dentate line (a mucocutaneous junction that lies about 1 to 1.5 cm above the anal verge), and an external hemorrhoid originates below this line. "If the surgeon does not directly state 'internal' or 'external' hemorrhoid, you can read further into the documentation to see if there is a reference to the dentate line," Dunaway says. If the documentation is unclear, you should be sure to consult with the surgeon before progressing.

2. Choose Treatment for Internal Hemorrhoids

For persistent internal hemorrhoids, surgeons have several treatment choices. "By far the most common hemorrhoid removal procedure is simple rubber-band ligature (46221, Hemorrhoidectomy, by simple ligature [e.g., rubber band])," Dunaway says. In this procedure, the surgeon "ties off" (ligates) the hemorrhoid at its base, which cuts off its blood supply and causes it to shrink over time.
 
For patients who require simple hemorrhoid removal by ligature, the surgeon may remove more than one hemorrhoid during the same session. Although some carriers may pay for each hemorrhoid removed, most will not. The AMA's CPT Assistant (October 1997) instructs physicians to bill 46221 only once per operative session regardless of how many hemorrhoids they band at that time.
 
Aside from rubber-band ligature, CPT provides codes to describe less-frequent methods of removing internal hemorrhoids, none of which are described by hemorrhoidectomy codes 46221-46262. These include:
 

Because the descriptors for both 46500 and 46934 specify "hemorrhoids" (plural), you should report these codes only once per session, regardless of how many hemorrhoids the surgeon treats, says Barbara Johnson, CPC, a coding expert with Loma Linda University Medical Group.

3. Determine if Hemorrhoids Are Thrombosed

External hemorrhoids can be thrombosed (clotted) or not, which determines treatment and coding options.
 
When treating a thrombosed external hemorrhoid, the surgeon has three options, Dunaway says:
 
1. Wait until the hemorrhoid develops into a skin tag and then, if appropriate, remove it.

2. Perform an incision and drainage (I&D) to remove the clot only.
 
3. Perform an excision to obliterate the clot and hemorrhoid at the same time.

In the first case and assuming that the surgeon does decide to proceed with removal you should report either 46220 (Papillectomy or excision of single tag, anus [separate procedure]) or 46230 (Excision of external hemorrhoid tags and/or multiple papillae), depending on whether the surgeon removes a single or multiple tag(s).
 
If the surgeon chooses the second option, you should report 46083 (Incision of thrombosed hemorrhoid, external).
 
For excision of the hemorrhoid and clot, your best code choice is 46320* (Enucleation or excision of external thrombotic hemorrhoid), Dunaway says.
 
Unlike banding, the excision and I&D of a thrombosed hemorrhoid describes only one removal. If the surgeon removes one or more additional thrombosed hemorrhoids, you should bill them separately.

4. For Nonthrombosed External Hemorrhoid: 46250

"If the surgeon provides excision of a non-thrombosed, external hemorrhoid or hemorrhoids only, you have only one code choice: 46250
(Hemorrhoidectomy, external, complete)," Johnson says. Code 46250 can describe removal of a single or several hemorrhoids, according to the Coder's Desk Reference. Johnson reminds coders not to confuse this code with 46320, which describes removal of a single, thrombosed hemorrhoid.
 
For removal of one or more external hemorrhoids by any method other than excision, choose 46935 (Destruction of hemorrhoids, any method; external). This code, like 46934, can include electrical current, infrared radiation and other methods, and applies to one or more hemorrhoids. 

5. For External and Internal, Report 46255, 46260

If the surgeon excises both external and internal hemorrhoids during the same session, you shouldn't choose one of each code from the external and internal excision codes. Instead, you should use 46255 (Hemorrhoidectomy, internal and external, simple) or 46260 (Hemorrhoidectomy, internal and external, complex or extensive). Codes 46255 and 46260 are nearly identical, although apparently 46255 involves a single column and 46260 involves multiple columns, the Coder's Desk Reference states. In either procedure, 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. Based on the number and size of hemorrhoids removed, the physician must make a subjective judgment to choose 46255 or 46260, Dunaway says. To support your coding claim, you must be sure that the physician's documentation justifies the selection of 46260 by noting the determining factors.
 
Once again, CPT provides a code, 46936 (Destruction of hemorrhoids, any method; internal and external), to describe destruction of internal and external hemorrhoids by any method other than excision.
 
All of the above codes (46255, 46260 and 46936) apply to single or multiple removals during the same operative session. In other words, if the surgeon excises two internal hemorrhoids and one external hemorrhoid during the same operation, you should report only a single unit of 46255, Johnson says.
 

Next month: Part two will discuss sphincterotomy, fissurectomy and fistulectomy, as well as reporting E/M procedures and scopes with hemorrhoidectomy.