General Surgery Coding Alert

Question: The surgeon performed a flexible sigmoidoscopy for a patient who presented with rectal bleeding. The surgeon diagnosed internal hemorrhoids and performed band ligation. How should we code this?

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Answer: The correct code for the procedure is 45350 (Sigmoidoscopy, flexible; with band ligation(s) (eg, hemorrhoids)).

A sigmoidoscopy refers to a procedure in which the surgeon accesses the rectum and lower one third of the colon with a flexible sigmoidoscope, which is a tubular instrument with a light source and camera.

If the surgeon had found nothing that required a therapeutic intervention, you would instead report 45330 (Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)).

Diagnosis: You don't give a lot of detail, so the most specific ICD-10 code you could report for this case would probably be K64.8 (Other hemorrhoids). Although you do provide documentation of bleeding, without specific information regarding prolapse or mention of hemorrhoid "degree," you can't accurately apply a more detailed code such as one of the following:

• K64.0 (First degree hemorrhoids)
• K64.1 (Second degree hemorrhoids)
• K64.2 (Third degree hemorrhoids)
• K64.3 (Fourth degree hemorrhoids).