Gastroenterology Coding Alert

Reporting hemorrhoidectomies performed in conjunction with endoscopies is not always allowed. So follow four steps to determine appropriate coding. 1.Know the Treatment Methods Although gastroenterologists rarely treat hemorrhoids alone, they may discover internal hemorrhoids while performing an endoscopy and elect to remove the enlarged blood vessels with rubber-band ligation or cauterization, experts say. For instance, a gastroenterologist may perform a colonoscopy on a patient who has rectal bleeding and may find the only cause of the bleeding is some hemorrhoid veins. If the gastroenterologist removes the hemorrhoids using a rubber-band ligation procedure, report 46221 (Hemorrhoidectomy, by simple ligature [e.g., rubber band]). Banding encompasses securing a tiny rubber band around the hemorrhoid to shut off its blood supply. Within a week, the hemorrhoid shrivels and falls off.

Remember to assign 46221 once only, even if multiple rubber bands are used around one hemorrhoid or multiple hemorrhoids are removed. CPT Assistant October 1997 instructs coders, "Each session of rubber-band ligation, regardless of the number of hemorrhoids, is coded once."

"If the doctor uses a probe to cauterize the hemorrhoid, select the appropriate code depending on the location(s) of the hemorrhoids," says Jennifer Bahm, CPC, for George Chin, MD, in Aurora, Colo. Although three codes describe cauterization, gastroenterology coders will usually use the code for internal hemorrhoid removal.

Here's the site breakdown of the cauterization codes: Internal 46934 (Destruction of hemorrhoids, any method; internal) External 46935 ( external) Internal and external 46936 ( internal and external). 2.Check If Procedures Are Bundled After selecting the appropriate hemorrhoid procedure performed, consider whether the hemorrhoid code is a component of the primary procedure that the gastroenterologist performed. In the above example of the gastroenterologist who performs a colonoscopy, neither banding nor cauterizations are included in the colonoscopy codes. Therefore, both procedures may be reported (see using modifier -51, below). However, the Correct Coding Initiative bundles rubber-band ligation code 46221 with three anoscopy codes: 46600 (Anoscopy; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), 46604 ( with dilation [e.g., balloon, guide wire, bougie) and 46606 ( with biopsy, single or multiple), Bahm notes. Therefore, you cannot report both the banding and the anoscopy. You should bill only the higher-valued procedure in this case, experts recommend. The 2002 National Physician Fee Schedule Relative Value File assigns 3.96 nonfacility relative value units (RVUs) for 46221, which is higher than the nonfacility RVUs for the anoscopy codes. (Code 46600 contains 1.36 nonfacility RVUs. Anoscopy with dilation code 46604 is valued at 2.39 nonfacility RVUs. Code 46606 has 1.75 nonfacility RVUs.) So, report the rubber-band ligation only. 3. Append Modifier -51 to the Lower-Valued Code For endoscopic procedures, such as colonoscopies and flexible sigmoidoscopies, which [...]