General Surgery Coding Alert

Do you know a fissurectomy from a fistulectomy from a fistulotomy? And how would you code each of these? Procedures associated with hemorrhoidectomy can raise troubling questions about bundling issues. Armed with expert advice, however, you can tackle these coding challenges with confidence every time.

Use One Code for Fissurectomy and Hemorrhoidectomy

You should report fissurectomy along with hemorrhoidectomy using either 46257 (Hemorrhoidectomy, internal and external, simple; with fissurectomy) or 46261 (Hemorrhoidectomy, internal and external, complex or extensive; with fissurectomy), says Terry Fletcher, BS, CPC, CCS-P, an independent surgery coding specialist in Laguna Beach, Calif.
 
You must choose between the simple (46257) or complex (46261) removal codes based on the surgeon's subjective judgment. The surgeon's documentation must support the selection of the "complex" removal code by noting the factors that define the excision as complex (for instance, the number and size of hemorrhoids removed), says M. Trayser Dunaway, MD, a general surgeon in Camden, S.C.
 
Note: For fissurectomy without hemorrhoidectomy, report 46200 (Fissurectomy, with or without sphincterotomy).
 
Include Hemorrhoidectomy With Fistulectomy

When reporting fistulectomy (either with or without fissurectomy) at the same time as hemorrhoidectomy, you should choose either 46258 (Hemorrhoidectomy, internal and external, simple; with fistulectomy, with or without fissurectomy) or 46262 (Hemorrhoidectomy, internal and external, complex or extensive; with fistulectomy, with or without fissurectomy), Dunaway says. Again, code selection depends on the complexity of the hemorrhoidectomy as described by the surgeon's documentation. CPT does not contain a separate code to describe only the fistulectomy with or without fissurectomy (the procedure always includes hemorrhoidectomy).
 
Fissurectomy is a more involved procedure than fistulotomy (which the surgeon may nevertheless perform at the same time), and involves excising an anal fistula, or passageway, that forms when an infected crypt (or blind pit) drains to the skin. The surgeon may choose either to remove the fistula entirely (fistulectomy) or to remove only the "roof" of the fistula (fistulotomy). Codes 46258 and 46262 are appropriate for fistulotomy as well as fistulectomy.

Report Sphincterotomy as a 'Separate Procedure'

 Be careful when reporting sphincterotomy (46080*, Sphincterotomy, anal, division of sphincter [separate procedure]): CPT classifies this as a "separate procedure," so you cannot bill for it if the surgeon performs any related procedures, including hemorrhoidectomy. In other words, you may report sphincterotomy only when it is the only procedure performed in the general anatomic area, Fletcher says.
 
For example, if the surgeon excises three internal hemorrhoids by banding and performs a sphincterotomy at the same time, you may report only 46221 (Hemorrhoidectomy, by simple ligature [e.g., rubber band]) because the sphincterotomy is automatically included in any related procedure. If, however, the surgeon excises the hemorrhoids and then, several months later, returns to the operating room to perform sphincterotomy only for the same patient, you can report 46221 for the first surgery and 46080 for the second.