General Surgery Coding Alert
Beware Upcoding to Anal Excision
Question: Patient presented with anal bleeding from a large vessel underneath a site where a hemorrhoid had necrosed and fallen off. Under anesthesia, the surgeon used a bivalve to suction old blood and suture the bleeding site. How should we code this?
Missouri Subscriber
Answer: The procedure you describe is a rectal exam under anesthesia (45990, Anorectal exam, surgical, requiring anesthesia [general, spinal, or epidural], diagnostic).
Watch for edits: Do not report 45990 with 45300-45327 (Proctosigmoidoscopy), 46600 (Anoscopy; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), 57410 (Pelvic examination under anesthesia), and 99170 (Anogenital examination with colposcopic magnification in childhood for suspected trauma), according to Medicare's Correct Coding Initiative (CCI) edits.
Physician responsibility: The surgeon will typically perform anorectal exam by placing the patient in left lateral decubitus position to study anal bleeding due to conditions such as fissures, fistula, and hemorrhoids. The patient receives general, spinal or epidural anesthesia and the physician performs a diagnostic digital rectal exam before inserting an anoscope to visualize the anal canal and distal rectum.
Because the surgeon did not excise any tissue in your example, such as hemorrhoids or fissure, you should not use an excision code such as 46200 (Fissurectomy, including sphincterectomy, when performed) or 46320 (Excision of thrombosed hemorrhoid, external). You can only report the exam code, which will include the suture service.
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Beware Upcoding to Anal Excision
Question: Patient presented with anal bleeding from a large vessel underneath a site where a [...]
