Navigate Your Way to Proper Internal-External Hemorrhoid Coding

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Do not miss CPT 2010 ‘either/or’ instruction for hemorrhoid location.

You cannot select a hemorrhoidectomy code if you do not know the distinction between internal and external hemorrhoids. Let our experts take you through the anatomy and coding maze to help you select the right code.

Location should guide you

According to Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPCP, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program, “External hemorrhoids occur outside the ‘anal verge,’ which is at the distal end of the anal canal.”

On the other hand, “internal hemorrhoids are proximal to the anal verge and can be much tougher to diagnose and treat,” she carries on.

Important to identifying different hemorrhoid types is… the dentate line. The line is a mucocutaneous junction about a cm above the anal verge, and “can be seen separating the anus from the rectum,” says Suzan Berman, CPC, CEMC, CEDC, senior manager of coding and compliance in the surgery and anesthesiology departments at the University of Pittsburgh Medical Center. Internal hemorrhoids take place above the dentate line, and external hemorrhoids occur below the line.

Best option: Knowing the lingo might help you translate op notes, however having your physician indicate “internal” or “external” will bring down any potential coding mistakes.

Look for ‘Internal’ Excision Instruction

Lack of specific internal hemorrhoid excision codes can be perplexing.

For example: “The only code I can come up with the excision of one internal hemorrhoid is the unlisted code 46999 (Unlisted procedure, anus),” according to Sandra Sickler CPC, CCS, coder with Countryside Surgery Center in Clearwater, Fla.

Here’s a solution: By adding the following text note, this year’s CPT codes allow you to utilize certain codes for internal and/or external hemorrhoids: “For excision of internal and/or external hemorrhoid(s), look at 46250-46262, 46320.” That means you can use 46255 (Hemorrhoidectomy, internal and external, single column/group) for the excision of one internal hemorrhoid (or 46260 [… 2 or more columns/groups] for excision of multiple internal hemorrhoids), according to Bucknam.

You might go for 46945 (Hemorrhoidectomy, internal, by ligation other than rubber band; single hemorrhoid column/group) or 46946 (… 2 or more hemorrhoid columns/groups) for certain internal hemorrhoid excisions, says Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta. Called “transfixion suture excision”, the surgeon places a crisscross stitch and ties off the base of the hemorrhoid with the suture (ligation) to be in charge of bleeding. Then the surgeon excises and does away with the remaining hemorrhoid.

One more problem: Your surgeon might excise a thrombosed internal hemorrhoid, however 46320 (Excision of thrombosed hemorrhoid, external) describes an external hemorrhoid procedure. Based on the new text note for internal and/or external codes, you can report 46320 for internal hemorrhoids, says Bucknam.

Follow ‘External’ Rules for the Right Code Choice

Even though the new text note for internal and/or external codes might seem to allow 46255 for a single external hemorrhoid, a separate text note following 46250 directs, “for hemorrhoidectomy, external, single column/group, go for 46999.”

Likewise, for excision of multiple external hemorrhoids you should make use of the most specific code 46250 (Hemorrhoidectomy, external, 2 or more columns/groups) rather than 46260.

Look at ‘Internal and External’ Codes for ‘Mixed’ Removals

Your surgeon may excise a “mixed” or confluent hemorrhoid that starts above the dentate line and extends below it. These hemorrhoids show attributes of both an external and internal hemorrhoid. You can find out what codes you should select by subscribing to the General Surgery Coding Alert.

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