"Hemorrhoids are either internal or external," says M. Trayser Dunaway, MD, FACS, a general surgeon in Camden, S.C. "In some cases, the surgeon may deal with both kinds during the same session. But whatever the circumstances, the codes you'll report are directly related to the location of hemorrhoids involved."
An internal hemorrhoid originates above the dentate line (a mucocutaneous junction that lies about 1 to 1.5 cm above the anal verge), and an external hemorrhoid originates below this line. "If the surgeon does not directly state 'internal' or 'external' hemorrhoid, you can read further into the documentation to see if there is a reference to the dentate line," Dunaway says. If the documentation is unclear, you should be sure to consult with the surgeon before progressing. 2. Choose Treatment for Internal Hemorrhoids For persistent internal hemorrhoids, surgeons have several treatment choices. "By far the most common hemorrhoid removal procedure is simple rubber-band ligature (46221, Hemorrhoidectomy, by simple ligature [e.g., rubber band])," Dunaway says. In this procedure, the surgeon "ties off" (ligates) the hemorrhoid at its base, which cuts off its blood supply and causes it to shrink over time.
For patients who require simple hemorrhoid removal by ligature, the surgeon may remove more than one hemorrhoid during the same session. Although some carriers may pay for each hemorrhoid removed, most will not. The AMA's CPT Assistant (October 1997) instructs physicians to bill 46221 only once per operative session regardless of how many hemorrhoids they band at that time.
Aside from rubber-band ligature, CPT provides codes to describe less-frequent methods of removing internal hemorrhoids, none of which are described by hemorrhoidectomy codes 46221-46262. These include:
46500* Injection of sclerosing solution, hemorrhoids. In this procedure, the surgeon injects a sclerosing solution into the submucosa of the rectal wall under the hemorrhoid. Once again, this reduces blood flow to the area and causes the hemorrhoid to shrink.
46934 Destruction of hemorrhoids, any method; internal. This is a "catchall" code to describe any method of destruction other than ligature or sclerosing solution. Such methods could include the use of electrical current or infrared radiation, Dunaway says. Because the descriptors for both 46500 and 46934 specify "hemorrhoids" (plural), [...]