General Surgery Coding Alert

One note allows mixed codes for internal procedures.

A quick glance at the CPT® “Anus” section reveals three codes specifically for internal hemorrhoids. That might lead you to believe those are your only choices when your general surgeon treats internal hemorrhoids — but you would be wrong — and missing the other choices could cost your surgery practice plenty. 

Let our experts walk you through the fine print to make sure you accurately report your surgeon’s work and capture all the pay she deserves for treating internal hemorrhoids.

Coder background: Hemorrhoids are a plexus of veins present in the anal canal that aid the smooth movement of stools. These veins cause concern only when they become inflamed or begin to bleed. The key to identifying different hemorrhoid types is the dentate line, which is a mucocutaneous junction about a centimeter above the anal verge that can be seen separating the anus from the rectum, explains Suzan Berman (Hauptman), MPM, CPC, DEDC, CEMC, manager of physician compliance auditing at Allegheny Health Network in Pittsburgh, Penn.

Best bet: Because coders may not have the clinical expertise to decode an op note about the dentate line, surgeons can save time and money by specifying if the hemorrhoids are internal and/or external, advises Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with PeaceHealth in Vancouver, Wash.

Focus Your Internal Ligation Choices

If your surgeon removes internal hemorrhoids by ligation, you have three clear code choices: 

• 46221 — Hemorrhoidectomy, internal, by rubber band ligation(s) 
• 46945 — ... by ligation other than rubber band; single hemorrhoid column/group 
• 46946 — ... by ligation other than rubber band; 2 or more hemorrhoid columns/groups.

If your surgeon uses rubber band ligation for internal hemorrhoids, you should report 46221. 

Caution: “Do not overuse 46221,” says Michael Weinstein, MD, a physician at Capital Digestive Care in Washington, D.C., and former representative of the AMA’s CPT® Advisory Panel. The most common treatment for internal hemorrhoids is rubber band ligation. The procedure report may contain a phrase such as “band ligator,” “CRH O’Regan system,” or “multi-band ligator.” For any of these internal hemorrhoid removals, the correct code is 46221 used just once even if multiple bands are performed during the procedure, according to Weinstein.

For internal hemorrhoid ligation using “other than rubber band,” look to 46945 or 46946.

Do this: When your surgeon removes more than one hemorrhoid by a non-rubber band technique, you need to concentrate on the number of columns rather than the actual number of hemorrhoids to choose the right code. According to CPT® guidelines, three different positions in the anal canal will form anal columns: right posterior, right anterior, and left lateral positions. 

Excision is Different

What if your surgeon performs an internal hemorrhoidectomy by excision rather than ligation? 

Concern: You might be hesitant to use the following two codes because the definition states, “internal and external”:

• 46255 — Hemorrhoidectomy, internal and external, single column/group 
• 46260 — ... 2 or more columns/groups. 

Solution: By including the following text note, CPT® allows you to use certain codes for internal and/or external hemorrhoids: “For excision of internal and/or external hemorrhoid(s), see 46250-46262, 46320.” That means you can use 46255 for the excision of one internal hemorrhoid or 46260 for excision of multiple internal hemorrhoid columns, according to Bucknam.

Pay dirt: Catching that one little text note and correctly reporting 46260 when your surgeon excises multiple columns of internal hemorrhoids, instead of erroneously reporting internal hemorrhoidectomy code 46946, could earn your practice an additional $255. That’s because 46946 pays $225, while 46260 pays $484 for the 2014 Medicare physician fee schedule national facility rate, conversion factor 35.8228.

Turn Elsewhere for Destruction

If your surgeon treats internal hemorrhoids by a destruction technique rather than ligation or excision, you’ll need to look beyond the previously-mentioned codes.

Do this: For hemorrhoid destruction by sclerotherapy, report 46500 (Injection of sclerosing solution, hemorrhoids). For internal hemorrhoid destruction using thermal energy, bill 46930 (Destruction of internal hemorrhoid[s] by thermal energy [e.g., infrared coagulation, cautery, radiofrequency]).