What’s New Where the Sun Doesn’t Shine?

Here’s the information you need to code anal surgery in 2010.

By G. John Verhovshek, MA, CPC

The anal surgery section (46020-46999) of CPT® 2010 contains nearly two dozen added, deleted, or altered codes from 2009. A quick review of these changes will keep your claims clean in the year ahead.

Fistula Plug Repair Gains a Category I Code

An anorectal fistula is an unnatural passage between the anal canal and the skin’s surface. Typically, such fistulae originate in anal crypts, which are tiny mucus glands located at the mucocutaneous junction. An infected crypt may become abscessed; when the abscess ruptures a fistula is formed.

2016 HCPCS Level

As an alternative to treatment with fibrin glue (CPT® 46706 Repair of anal fistula with fibrin glue), surgeons may choose to place a sterile, biodegradable, porcine small intestine submucosa “plug” to fill the fistula. The surgeon fixes the plug from the inside of the anus with a suture, which allows the fistula to heal from the inside out. For 2010, Category I code 46707 Repair of anorectal fistula with plug (eg, porcine small intestine submucosa [SIS]), which replaces deleted Category III code 0170T, should be used to report this treatment.

Crypectomy Becomes an Unlisted Procedure

Crypectomy is the excision of an (infected) anal crypt to prevent the formation of anorectal fistula as described above. Two codes previously used to report crypectomy — 46210 (for a single cryptectomy) and 46211 (for multiple cryptectomy) — were removed from CPT® because, as explained in CPT® Changes 2010: An Insider’s Guide, the procedures “are rarely performed in current practice.” In those rare cases when crypectomy is performed, select unlisted procedure code 46999 Unlisted procedure, anus.

Hemorrhoid Codes Change, Coding Doesn’t

The greatest number of changes to the anal surgery section of CPT® involves revisions to hemorrhoid treatment and related codes, including many descriptor revisions and several re-sequenced codes. Those familiar with the codes will find the code application has not changed, however.

Hemorrhoids are simply blood vessels, which require attention only if they become inflamed. Correct coding depends on documentation that specifies the type (internal, external, or “mixed”) and number of hemorrhoids treated, as well as the treatment method.

Resource tip: For a review of hemorrhoid anatomy and terminology, see “Don’t Let Hemorrhoid Codes Be a Pain,” February 2009 Coding Edge, pages 30-32.

Codes to identify treatment for internal hemorrhoids have minor descriptor revisions to clarify application, while two codes have been re-sequenced from the Destruction subhead to appear more appropriately under the Excision subhead. Other relevant codes are unchanged for 2010, but CPT® adds specific instruction for appropriate code application, as outlined below, just after the Anus subhead.

Surgical Treatment: Internal Hemorrhoid Coding-at-a-Glance

Treatment                         Single Column/Group             Multiple Columns/Groups

Rubber band ligation         ♦    46221*

Other Ligation (suture)       #♦  46495                                #♦  46496

Sclerosing Injection                 46500*

Thermal energy                        46930*

Cryosurgery                             46999*

Hemorrhoidopexy                   46947*

# Resequenced code

♦ Revised code
* Report only a single code unit, regardless of how many hemorrhoids are treated

Coding for surgical treatment of external hemorrhoids can depend on whether the vessel is thrombosed (clotted). Once again, several code descriptors are revised for clarity.

Surgical Treatment: External Hemorrhoid Coding-at-a-Glance

Thrombosed?                    Single Column/Group             Multiple Columns/Groups

Yes                                    #    46320                                      46320 x number of hemorrhoids excised

No                                           46999                                ♦    46520

# Resequenced code
♦ Revised code

Note: A surgeon may choose to treat a thrombosed external hemorrhoid simply by draining (by incision) the clot only, after which the varicose hemorrhoid may resolve on its own. Such a procedure is reported with 46083 Incision of thrombosed hemorrhoid, external, as directed by new text added just after the Anus subhead in CPT®.

An external thrombosed hemorrhoid may resolve into a skin tag or papilla, which the surgeon may remove. Removal of a single tag/papilla is reported with 26220 Excision of single external papilla or tag, anus, while removal of two or more tags/papillae is reported with 26230 Excision of multiple external papillae or tags, anus. Report only a single unit of 26230 per claim, and never report 26220 and 26230 on the same claim. Note that these codes have minor descriptor revisions (with no change in application) for 2010.

Coding for so-called “mixed hemorrhoid” treatment depends on both the number of groups/columns treated, as well as any related procedures performed at the same time. Numerous code descriptors in this category are revised to clarify code application as established in previous years.

Surgical Treatment: Mixed Hemorrhoid Coding-at-a-Glance

Single Column/Group

Excision Alone                        With Fissurectomy                   With fistulectomy (including fissurectomy when performed)

♦ 46255                                   46257                                      ♦ 46258

Multiple Columns/Groups

Excision Alone                        With Fissurectomy                   With fistulectomy (including fissurectomy when performed)

♦ 46260                                   46261                                      ♦ 46262

♦ Revised code

Anal Fistula Codes Get a Makeover

Finally, CPT® has revised descriptors for several codes related to treatment of anal fistula (an unnatural passage that forms between the surface of the skin and the anus). Fistulas most commonly are caused by bowel diseases, such as ulcerative colitis and Crohn’s disease. Treatment may include fistulectomy or fistulotomy. Fistulotomy involves opening the anal fistula, draining any pus or other fluid, and merging the fistula tract with the anal canal to allow the fistula to heal. Fistulectomy involves complete excision of the fistula.

Language for 46275 Surgical treatment of anal fistula (fistulectomy/fistulotomy); intersphincteric has been revised to specify intersphincteric rather than submuscular. Code 46280 Surgical treatment of anal fistula (fistulectomy/fistulotomy); transsphincteric, suprasphincteric, extrasphincteric or multiple, including placement of seton, when performed has undergone a similar revision, and now specifies location rather than simply stating “complex.” Code 46270 Surgical treatment of anal fistula (fistulectomy/fistumotomy); subcutaneous remains unchanged for 2010.

The Bottom Line

Codes and guidelines in the Anal Surgery section of CPT® not discussed above receive no changes for 2010. With the exception of substituting 46707 for a now-deleted Category III code, and substituting an unlisted procedure code for now-deleted crypectomy codes, code application in this portion of CPT® does not change from previous years. Note, however, new (and clearer) code language may alter the way in which the surgeon documents procedures. This will be especially important with regard to:

  • Surgical treatment of anal fistula(e), the location of which should be documented precisely, and;
  • For hemorrhoid surgery, the exact number of columns/groups addressed, rather than a simple statement of “simple” or “complex.”

One Response to “What’s New Where the Sun Doesn’t Shine?”

  1. robi says:

    my dr started out with a stapled rectopexy this went well on the right side, but the staple line was incomplete on the left so he excised the hemorrhoid on the left side what code or codes should be submitted im wondering if a 46947 and 46255 could be coded together

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