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Differentiate methods to select the right code.

Hemorrhoid surgery has never encompassed just one single procedure code. General surgeons may use a wide range of operative techniques to treat hemorrhoidal disease, and each surgical strategy can be assigned dramatically different CPT^® codes.

For that reason, accurate coding depends on understanding exactly what the surgeon performed rather than simply assigning a generic hemorrhoidectomy code based on the diagnosis.

The operative report should clearly identify whether the patient’s hemorrhoids were excised, ligated, stapled, or treated because of thrombosis. You’ll also want to identify the number and location of hemorrhoids involved so you can select the most appropriate diagnosis and procedure codes.

Keep reading to discover how to code your surgeon’s hemorrhoid procedures correctly every time.

Note Location for Excisional Hemorrhoidectomy

During an excisional hemorrhoidectomy, the surgeon cuts hemorrhoids out of the patient’s tissue using a heated device or a scalpel. You’ll find the codes for these services in the 46250-46262 (Hemorrhoidectomy …) range of your CPT^® code book.

But choosing the correct code requires attention to whether the hemorrhoids are external or both internal and external. You’ll also need to know how many columns or groups were involved.

What this means: Hemorrhoid columns, also called hemorrhoid groups, are vascular structures located in the anus. Everyone has them, but if they become swollen or inflamed, they can irritate the patient and may even bleed, which is why the surgeon may treat them. Your surgeon will typically treat between one and three hemorrhoid columns.

These are the most common codes for hemorrhoid excisions:

• 46250 (Hemorrhoidectomy, external, 2 or more columns/groups): Report this code when the surgeon excises external hemorrhoids in two or more columns or groups.
• 46255 (Hemorrhoidectomy, internal and external, single column/group): Assign this code if the surgeon excises internal and external hemorrhoids involving a single column or group.
• 46257 (Hemorrhoidectomy, internal and external, single column/group; with fissurectomy): Use this code if the surgeon performs the procedure listed in 46255 and they also perform a fissurectomy.
• 46258 (Hemorrhoidectomy, internal and external, single column/group; with fistulectomy, including fissurectomy, when performed): You’ll report this code when the hemorrhoidectomy is accompanied by a fistulectomy and a fissurectomy.

The key to pinpointing the correct code is to read the operative report carefully. The distinction between one column and two or more columns can change the code substantially. The documentation should support the number and type of hemorrhoidal groups removed and any additional surgical procedures.

Diagnosis coding: To select the right ICD-10-CM diagnosis code, check the documentation for the hemorrhoid degree, which your surgeon may document as the hemorrhoid “grade” instead of “degree.” The degree or grade describes the hemorrhoid’s severity.

You’ll select a code from the K64.- (Hemorrhoids and perianal venous thrombosis) category, depending on the degree. For instance, if the patient has a third-degree hemorrhoid, you’ll report K64.2 (Third degree hemorrhoids).

Avoid 4625x Codes for Stapled Procedures

Stapled hemorrhoidopexy is a different procedure from conventional excisional hemorrhoidectomy. During the stapled procedure, the surgeon lifts and secures swollen tissue using a unique stapling device. You shouldn’t report this procedure using one of the 46250-46258 codes.

Instead, you’ll report 46947 (Hemorrhoidopexy (eg, for prolapsing internal hemorrhoids) by stapling) for the stapling procedure.

The diagnosis should reflect how the physician documented the hemorrhoidal condition. For instance, if the surgeon is addressing a fourth-degree hemorrhoid, you’ll report K64.3 (Fourth degree hemorrhoids).

It’s important not to confuse stapled hemorrhoidopexy with other minimally invasive hemorrhoid procedures.

For example, 46948 (Hemorrhoidectomy, internal, by transanal hemorrhoidal dearterialization, 2 or more hemorrhoid columns/groups, including ultrasound guidance, with mucopexy, when performed) describes transanal hemorrhoidal dearterialization of two or more internal hemorrhoid columns/groups. That’s a different technique than what’s described by 46947.

Differentiate Incision vs. Excision for Thrombosed Hemorrhoids

Thrombosed hemorrhoids require another coding distinction. Treatment may consist of either incision of the thrombosed hemorrhoid or excision, and these services have different procedure codes.

Code 46083 (Incision of thrombosed hemorrhoid, external) describes the incision of an external thrombosed hemorrhoid. During this procedure, the surgeon incises (cuts) the hemorrhoid and drains it to quickly alleviate pain and pressure.

Use 46320 (Excision of thrombosed hemorrhoid, external) when the surgeon cuts the blood clot out of the swollen vein. The procedure report should make clear which service was actually performed.

The corresponding ICD-10-CM code is generally K64.5 (Perianal venous thrombosis) when the physician documents a thrombosed hemorrhoid/perianal venous thrombosis.

The thrombosed hemorrhoid codes are particularly important to know because 46320 should never be substituted for an excisional hemorrhoidectomy code. Some coders may lean toward the excisional hemorrhoidectomy codes simply because the surgeon removed a hemorrhoid. But a thrombosed external hemorrhoid is a specific clinical condition with its own procedure code. Likewise, an incision and evacuation of a thrombosed hemorrhoid is not the same service as complete excision.

If you’re unsure which code applies, check the procedure report. If the code choice is still unclear, speak directly with the surgeon for more information.

Torrey Kim, Contributing Writer, Raleigh, North Carolina