Part B Insider (Multispecialty) Coding Alert

When your surgeon evaluates a new patient or an established patient with a new problem, you can report an E/M services and diagnostic tests. But you can also report hemorrhoid procedures separately in some cases, says Kathleen Mueller, a general surgery coding and reimbursement specialist in Lenzburg, Ill.

For example, your surgeon sees a patient with rectal bleeding. She performs normal E/M services, plus a diagnostic proctosigmoidoscopy (45300), sigmoidoscopy (45330) and possibly even colonoscopy (45378) to identify some other cause for the bleeding besides hemorrhoids. Then the surgeon ligates several hemorrhoids using rubber bands (46221, Hemorrhoidectomy, by simple ligature [e.g., rubber band]).

You can report the E/M service supported by the surgeon's documentation (for instance, 99203) and scopes in addition to the hemorrhoidectomy. But you should use modifier -25 for the E/M service to differentiate it from the "inherent" E/M component of the other procedures (hemorrhoidectomy, scopes) provided on the same date, Mueller says.

Don't Bill Scopes for Established Patients

Typically, for established patients with known symptoms, you cannot claim scopes or E/M services in addition to rubber banding or other hemorrhoidectomy codes, Mueller says.

For instance, surgeons will often perform an anoscopy (46600) prior to hemorrhoidectomy for an established patient. The National Correct Coding Initiative bundles 46600 to 46221 and considers the anoscopy and any E/M as part of the preproce-dure evaluation for the banding (and therefore not separately payable).

The NCCI edit coupling 46600 and 46221 includes a "1" status indicator, meaning that if the physician performs an anoscopy for a separate problem (that is, if it is unrelated to the banding procedure), you may report it separately with modifier -59 (Distinct procedural service).

For example, for a patient with a history of colon cancer (V10.05), the surgeon may choose to provide a separate scope to check for additional problems beyond hemorrhoids. But in most cases, "you usually won't get paid for more than rubber banding for an established patient, unless the patient has significant additional problems," Mueller says.

If the surgeon knows that surgery is necessary and chooses to forgo an extensive office examination, which can be painful for the patient, and instead examines the patient in the operating room after anesthesia, you may not report a separate E/M service, says M. Trayser Dunaway, MD, a general surgeon in Camden, S.C. Although the exam may be extensive, the service is not separately identifiable and did not affect the surgeon's decision for surgery.

But you may bill an exam under anesthesia if the surgeon has not yet made a diagnosis. Anal problems can be quite painful, and often the surgeon cannot adequately examine the patient without anesthesia. As long as the documentation states this clearly, you may report an E/M service for such an examination with modifier -23 (Unusual anesthesia) appended.