Coding and Documenting Hemorrhoids – Using ICD-10 and CPT Codes

Coding and Documenting Hemorrhoids – Using ICD10 and CPT Codes

Hemorrhoids are swollen veins located around the outer part of the anus or the lowest part of your rectum. The blog lists the ICD-10 and CPT codes for the condition.

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Hemorrhoids are enlarged and swollen blood vessels or veins located around the outer part of the anus or the lowest part of your rectum. The rectum is the bottom section of the colon (large intestine) that leads to the anus (the opening at the end of the colon where fecal matter leaves the body). When the walls of these blood vessels are stretched, they become irritated and bleeding occurs. When the stretching and pressure continues, the weakened vessels protrude. Reports suggest that about half of the population experience one or more of the classic symptoms of hemorrhoids by the age of 55 years. Hemorrhoids are rarely dangerous, but they can be recurrent and easily treated. Proctologists or gastroenterologists treating hemorrhoids have to ensure accurate documentation of the patient’s condition and treatment provided. General surgery medical billing and coding is a more complex specialty than many others when it comes to reporting diagnosis and management, and many providers rely on medical billing and coding outsourcing companies to do so.

Also known as piles, hemorrhoids are very common in both men and women, affecting about 1 in 20 Americans. The likelihood of developing this condition increases as a person ages. In most cases, women are likely to develop the condition while pregnant.

Hemorrhoids can either be internal or external. Internal hemorrhoids develop within the anus or rectum. External hemorrhoids on the other hand, develop under the skin, outside the anus. In some cases, blood may pool in an external hemorrhoid and form a clot (thrombus) that can result in severe pain, swelling, inflammation and a hard lump near your anus which is known as thrombosed hemorrhoids.

Causes and Symptoms Hemorrhoids have a number of causes, although often the cause is unknown. Enlargement of the veins around the anus is considered one of the primary causes of hemorrhoids.

However, experts have identified several other factors such as – straining during bowel movements, complications from chronic constipation and diarrhea, sitting for a long period of time (especially on the toilet), and anal intercourse as the root causes for this condition.

The condition can also occur due to aging as the tissues that support the veins in your rectum and anus can weaken and stretch. Genetics, obesity, repeated heavy lifting of objects, lack of fiber in the diet and pregnancy can also cause this condition.

Typically, the type of symptoms depends on the location - whether the hemorrhoid is external (on the skin around the anus) or internal (inside the rectum) and its severity (from mild to debilitating). Common symptoms include -

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

Painless bleeding during bowel movements



Itching or irritation in your anal region



Swelling around your anus

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A lump near your anus, which may be sensitive or painful (may be a thrombosed hemorrhoid)

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Fecal leakage

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Painful bowel movements

How Are Hemorrhoids Diagnosed and Treated?

Diagnosis of this condition will generally begin with a detailed description of symptoms by patients along with previous medical history. Physicians may also look for symptoms like skin irritation, lumps or swelling, skin tags (excess skin left when the blood clot in a thrombosed hemorrhoid is absorbed by the body), external hemorrhoids, prolapsed internal hemorrhoids and anal fissures that can lead to itching and bleeding. External hemorrhoids are generally apparent, especially if a blood clot has formed.

Primary diagnosis of this condition will generally begin with a detailed visual examination of the anal and rectal (anorectal) area. In order to confirm the diagnosis, your physician may conduct a digital rectal exam to check for any abnormalities within the anus. During this exam, your physician will insert a gloved and lubricated finger into your rectum and if they feel anything abnormal, they may order an additional test called a sigmoidoscopy. A sigmoidoscopy

involves

your

doctor

using

a

small

fiber-optic

camera

(called

a

sigmoidoscope) to obtain a clear view of your rectum (inside) so that they can examine the hemorrhoid up close. In some cases, your physician may conduct colonoscopy to examine the entire colon if the patient’s symptoms suggest the occurrence of any other digestive system disease or have risk factors for colorectal cancer.

Treatment options for this condition include - over the counter (OTC) creams or suppositories (like hydrocortisone witch hazel, or lidocaine), oral pain relievers such as acetaminophen (Tylenol, others), aspirin or ibuprofen (Advil, Motrin IB, others) that help temporarily relieve your discomfort from hemorrhoids.

External hemorrhoid thrombectomy procedure is opted if a painful blood clot (thrombosis) has formed within an external hemorrhoid. Physicians can remove the clot with a simple incision and drainage. This procedure may provide prompt relief if done within 72 hours of developing a clot. Other minimally invasive procedures include - rubber band ligation, Injection (sclerotherapy) and Coagulation (infrared, laser or bipolar). For patients who have

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large hemorrhoids, physicians may recommend different surgical procedures such as – hemorrhoidectomy and stapled hemorrhoidectomy or stapled hemorrhoidopexy.

General surgery medical coding involves using the specific ICD-10 diagnosis codes, and CPT procedure codes for reporting different types of hemorrhoid on your medical claims.

ICD-10 codes 

K64 - Hemorrhoids and perianal venous thrombosis

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K64.0 - First degree hemorrhoids

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K64.1 - Second degree hemorrhoids

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K64.2 - Third degree hemorrhoids

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K64.3 - Fourth degree hemorrhoids

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K64.4 - Residual hemorrhoidal skin tags

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K64.5 - Perianal venous thrombosis

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K64.8 - Other hemorrhoids

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K64.9 - Unspecified hemorrhoids

CPT Codes 

43227 - Esophagoscopy, flexible, transoral; with control of bleeding, any method



43255 - Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method



44366 - Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)



44378 - Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)



44391 - Colonoscopy through stoma; with control of bleeding, any method



45334 - Sigmoidoscopy, flexible; with control of bleeding, any method



45382 - Colonoscopy, flexible; with control of bleeding, any method

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43205 - Esophagoscopy, flexible, transoral; with band ligation of esophageal varices

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43244 - Esophagogastroduodenoscopy, flexible, transoral; with band ligation of esophageal/gastric varices

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45350 - Sigmoidoscopy, flexible; with band ligation(s) (eg, hemorrhoids)



45398 - Colonoscopy, flexible; with band ligation(s) (eg, hemorrhoids)

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46221 - Hemorrhoidectomy, internal, by rubber band ligation(s)

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

46945 - Hemorrhoidectomy, internal, by ligation other than rubber band; single hemorrhoid column/group

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43192 - Esophagoscopy, rigid, transoral; with directed sub mucosal injection(s), any substance

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43201 - Esophagoscopy, flexible, transoral; with directed sub mucosal injection(s), any substance



43204 - Esophagoscopy, flexible, transoral; with injection sclerosis of esophageal varices



43236 - Esophagogastroduodenoscopy, flexible, transoral; with directed sub mucosal injection(s), any substance



43243 - Esophagogastroduodenoscopy, flexible, transoral; with injection sclerosis of esophageal/gastric varices



44404 - Colonoscopy through stoma; with directed sub mucosal injection(s), any substance



45335 - Sigmoidoscopy, flexible; with directed sub mucosal injection(s), any substance



45381 - Colonoscopy, flexible; with directed sub mucosal injection(s), any substance

To prevent or avoid worsening of hemorrhoid symptoms several effective lifestyle habits can be opted. Avoid over-straining during a bowel movement as this creates pressure in the veins in the lower rectum. Increase your intake of water on a regular basis as this will help prevent hard stools and aid in healing. Consuming plenty of foods rich in fiber, such as fruits and vegetables, as well as whole grains can ease constipation. In addition, keep the anal area clean – shower daily to cleanse the skin around your anus gently with warm water.

Medical coding for various general surgery procedures can be complex. Outsourcing the medical coding tasks to a reliable and professional medical billing company can help in accurate and timely medical billing and claims submissions. Experienced, AAPC-certified coding specialists in these companies are knowledgeable about the nuances of reporting this common general surgical procedure correctly.

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