General Surgery Coding Alert

Question: Our surgeon excised a second-degree internal hemorrhoid group due to uncontrollable rectal bleeding. How should we code this?

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Answer: For the surgical procedure, you should report 46255 (Hemorrhoidectomy, internal and external, single column/group).

The most specific ICD-10 code for the case is K64.1 (Second degree hemorrhoids). You should use this code because the surgeon documented that these are bleeding, second-degree hemorrhoids, which means that they prolapse but retract spontaneously.

Without that specific information in the op report, the coder would have to choose a less-specific code, such as K64.9 (Unspecified hemorrhoids).

Take away: Code the condition to the highest degree of specificity that you can, considering all the diagnostic information in the op report.