What E&M Code Do I Use For A Complete Phyiscal Navigate Your Way to Proper Internal-External Hemorrhoid Coding

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Navigate Your Way to Proper Internal-External Hemorrhoid Coding

Don’t miss CPT 2010’s “either/or” instruction regarding hemorrhoid location.

You cannot select a hemorrhoidectomy code if you do not know the difference between internal and external hemorrhoids. Our experts will guide you through the anatomy and coding maze to help you choose the right code.

The place should control

“External hemorrhoids occur outside the ‘anal border,’ which is about the distal end of the anal canal.”

On the other hand, “internal hemorrhoids are located near the anal rim and can be much more difficult to diagnose and treat,” he continues.

To identify the different types of hemorrhoids, it is important… the teeth. The line is a mucosal junction about 1 cm above the anal margin and “can be seen to separate the anus from the rectum,” says Suzan Berman, CPC, CEMC, CEDC, senior manager of coding and compliance for surgical and in anesthesiology departments. at the University of Pittsburgh Medical Center. Internal hemorrhoids are located above the line of teeth, and external hemorrhoids are located below the line.

Your best bet: Knowing the lingo can help translate the operative notes, but having your doctor label the term “internal” or “external” will reduce potential coding errors.

Find the “Inner” cut instruction

The lack of specific internal hemorrhoid excision codes can be confusing.

For example, “The only code I can find for excision of an internal hemorrhoid is code 46999 (unlisted procedure, anus),” according to Sandra Sickler CPC, CCS, a coder at Countryside Surgery Center in Clearwater.

Here is the solution: Adding the following textual note for this year CPT codes allows certain codes to be used for internal and/or external hemorrhoids: “For excision of internal and/or external hemorrhoid(s), see 46250-46262, 46320.” This means you can use 46255 (Hemorrhoidectomy, internal and external, one column/group) for excision of an internal hemorrhoid (or 46260 [… 2 or more columns/groups] for excision of multiple internal hemorrhoids), according to Bucknam.

Possibly 46945 (Hemorrhoidectomy, internal, with ligation, excluding the rubber band; single hemorrhoid column/group) or 46946 (… 2 or more hemorrhoidal columns/group) to excise certain internal hemorrhoids, says Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta. Called a “transfixation suture excision,” the surgeon places a cross-pad and ties the base of the hemorrhoid with a suture (ligation) to control the bleeding. The surgeon then cuts out and eliminates the remaining hemorrhoids.

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

Follow the “External” rules to select the appropriate code

Although the new text note for internal and/or external codes may appear to allow 46255 for a single external hemorrhoid, a separate text note following 46250 reads: “For external, single column/group hemorrhoidectomy enter 46999.”

Likewise, the most specific code 46250 should be used for excision of multiple external hemorrhoids.Hemorrhoidectomy, external, 2 or more columns/group) instead of 46260.

See “internal and external” codes for “mixed” removals

The surgeon can cut out “mixed” or confluent hemorrhoids that start above the dentition and extend below it. These hemorrhoids show characteristics of both external and internal hemorrhoids. You can find out what codes to select by subscribing to the General Surgery Coding Alert.

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