Medicare Compliance & Reimbursement

If your physician destroys internal hemorrhoids with heat, you changed your coding this year to rely on a code introduced in 2009: 46930 (Destruction of internal hemorrhoid[ s] by thermal energy [e.g., infrared coagulation, cautery, radiofrequency]). What may have been a surprise is that the new code treats the procedure as major surgery.

Here's how to know: 46930 has a 90-day global period.

So if your gastroenterologist performs thermal hemorrhoid destruction in stages, you'll have to append a modifier or risk losing as much as $189.71.

American Society for Gastrointestinal Endoscopy adviser Glenn D. Littenberg, MD, American Gastroenterology Association adviser Joel V. Brill, MD, and American College of Gastroenterology adviser Daniel C. DeMarco, MD, foresaw this problem. They recommended modifier 76 (Repeat procedure or service by same physician) in the American College of Gastroenterology's 2009 CPT update.

"It may be necessary to indicate that a procedure or service was repeated subsequent to the original procedure or service," the physicians wrote. "This circumstance may be reported by adding modifier 76 to the repeated procedure/service."

The codes for treating internal hemorrhoids have confused clinicians for years, partially because of all the possibilities.

CPT offers you several hemorrhoid excision codes: 46250-46262 (Hemorrhoidectomy, ...) and 46230 (Excision of external hemorrhoid tags and/or multiple papillae). With multiple codes to describe hemorrhoidectomy and yet another for hemorrhoidopexy -- a related but distinct procedure -- you can easily become overwhelmed when trying to report hemorrhoid removals. However, none of these codes specify that your surgeon only removed internal hemorrhoids. Having multiple hemorrhoid destruction codes further complicated matters.

Now, however, you have just one hemorrhoid destruction code thanks to CPT 2009. In January, the AMA deleted 46934-46936 (Destruction of hemorrhoids, any method ...) and added 46930.

Before filing your claim, take note that CPT code 46930 is not for incisions or excisions.

"Deletion of the three codes referenced, specifically incision and excision codes, for the creation of the new code allows more precise coding for nonexcisional procedures," according to the Jan. 2009 Bulletin of the American College of Surgeons.

More explanation: CPT 2009 appends a note to 46930 announcing the demise of the old hemorrhoid destruction codes and referring you to other codes with this clarification: "For incision of external thrombosed hemorrhoid(s), use 46083; for destruction of internal hemorrhoids by thermal energy, use 46930; for destruction of hemorrhoid(s) by cryosurgery, use 46999; for excision of hemorrhoid(s), see 46250-46262, 46320; for injection, use 46500; for ligation, see 46221, 46945, 46946; for hemorrhoidopexy, use 46947."

Location: Internal hemorrhoids originate above the dentate line (a mucocutaneous junction that lies about 1 to 1.5 cm above the anal verge). Use of a local anesthetic might be a tipoff that the surgeon treated an external hemorrhoid because internal hemorrhoids can usually be treated without pain. There is no longer a code for heatdestruction of external hemorrhoids.

The Correct Coding Initiative hits the new hemorrhoid destruction code 46930 with several bundling edits.

You won't be able to report 46930 with anesthesia code 00902, manipulation codes 45900-45915, anorectal exam code 45990, and more.

Modifier tip: You'll be able to use a modifier to break some of the new 46930 bundles -- for example, the bundle with nerve block codes 64415-64417 and new therapeutic, prophylactic, and diagnostic administration codes 96360-96375.

Doctors usually destroy hemorrhoids in their office, but many facilities allow these types of cases (despite low reimbursement for some CPT codes) in order to keep the physician performing procedures there.

When the physician evaluates a patient with a new problem, you may often report an appropriate-level E/M service and diagnostic scope code(s) in addition to the hemorrhoid procedures.

For instance: The physician sees a new patient with rectal bleeding. She provides an E/M service that includes a history and exam to determine if the patient has a personal or family history of colon cancer, diverticulitis, or other problems. The physician also performs a diagnostic proctosigmoidoscopy to determine whether a cause other than hemorrhoids is responsible for the bleeding.

The scope reveals no problems in the rectum, sigmoid, or colon. The physician destroys several hemorrhoids with thermal energy.

In addition to the hemorrhoid destruction, in this case you may report an E/M service (such as 99203, Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity) supported by the physician's documentation and scope results.

You must append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M service to differentiate it from the "inherent" E/M component of the other procedures (hemorrhoid destruction, proctosigmoidoscopy) provided on the same date.

Therefore, your claim would read 46930 for the hemorrhoid destruction, 99203-25 (for the E/M service), and 45300 (Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) for the proctosigmoidoscopy.