Part B Insider (Multispecialty) Coding Alert

Suture ligations may require another code--depending on the circumstances

Hemorrhoid location should influence the codes you choose for hemorrhoid removal. Here's why.

First step: Classify the type of hemorrhoid(s) involved.

"Hemorrhoids are either internal or external," explains M. Trayser Dunaway, MD, FACS, CSP, CHCO, CHCC, a surgeon, physician and coding educator, and healthcare consultant in Camden, SC. While a physician may deal with both kinds during the same session, you'll always code based on the location of the hemorrhoids involved, he says.

Definition: An internal hemorrhoid originates above the dentate line (a mucocutaneous junction above the anal verge). In contrast, an external hemorrhoid originates below this line.

Tip: If the physician does not directly state "internal" or "external," in the documentation, look for a reference to the dentate line, Dunaway suggests.

Coding clues: If the physician "ties off" (ligates) the hemorrhoid at its base to cut off its blood supply, you should select 46221 (Hemorrhoidectomy, by simple ligature [e.g., rubber band]). If the gastroenterologist removes more than one hemorrhoid by simple ligature during the same session, you should bill 46221 only once per operative session regardless of how many hemorrhoids the gastroenterologist bands at that time. Even if the physician removes two or more hemorrhoids by simple ligature, you should report only a single unit of 46221.

Beware: Don't confuse so-called "suture ligations" with simple ligations, or rubber banding, as described by 46221. Suture ligation (46945, Ligation of internatl hemorrhoids; single procedure; and 46946,...multiple procedures) is an altogether different procedure in which the physician isolates the hemorrhoid and ties the suture material to its base. As with rubber banding, the hemorrhoid will slough off as the suture strangulates blood flow.