The Food and Drug Administration (FDA) issued an updated safety communication July 13 warning health care providers and patients that surgical placement of mesh through the vagina to repair pelvic organ prolapse (POP) may do more harm than good.
“There are clear risks associated with the transvaginal placement of mesh to treat POP,” said William Maisel, MD, MPH, deputy director and chief scientist of the FDA’s Center for Devices and Radiological Health.
POP occurs when the internal structures that support the pelvic organs—such as the bladder, uterus, and bowel—become so weak or stretched that the organs drop from their normal position and bulge or prolapse into the vagina. While not a life-threatening condition, women with POP often experience pelvic discomfort, disruption of their sexual, urinary, and defecatory functions, and an overall reduction in their quality of life.
Surgery to repair POP can be performed through the abdomen or transvaginally, using stitches, or with the addition of surgical mesh to reinforce the repair and correct the anatomy.
Complications from surgical mesh used to repair POP, however, include mesh becoming exposed or protruding out of the vaginal tissue (erosion), pain, infection, bleeding, pain during sexual intercourse, organ perforation from surgical tools used in the mesh placement procedure, and urinary problems.
Additional surgeries or hospitalization are sometimes done to treat these complications or to remove the mesh. Unfortunately, Dr. Maisel said, “Mesh is a permanent implant—complete removal may not be possible and may not result in complete resolution of complications.”
The FDA recommends that health care providers:
- Recognize that in most cases, POP can be treated successfully without mesh;
- Know that surgical mesh is a permanent implant that can make any future surgical repairs more challenging and can put the patient at risk for additional complications and surgeries;
- Consider that mesh placed abdominally for POP repair may result in lower rates of mesh complications compared to transvaginal POP surgery with mesh; and
- Be sure that patients are aware of the risks and benefits of transvaginal POP repair with mesh, and inform patients if mesh is being used.
July 29th, 2011
Get the information you need to code hemorrhoid procedures accurately.
By Linda M. Farkas, MD
Everyone has blood vessels that lie at the junction of the rectum and anus. Straining during bowel movements due to diarrhea or constipation can cause these veins to swell and inflame. Decreased venous return to the heart, as with hypertension or pregnancy, can increase the risk of hemorrhoid disease. Hemorrhoids typically occur in the right posterior, right anterior, and left lateral positions. An accessory hemorrhoid is one found in an atypical location, such as right lateral.
Varicose hemorrhoids are rarely dangerous, and often resolve within a few days with minor or no treatment. Individuals who suffer significant bleeding or discomfort from prolapse, or who have persistent symptoms following conservative medical management, may require surgical intervention.
To code hemorrhoid procedures accurately, you need two pieces of information: the hemorrhoid type and the precise method of treatment. CPT® divides hemorrhoids at any position into three types: internal, external, and mixed.
Internal hemorrhoids originate above the dentate line. This is an actual, discernable line—also referred to as the pectinate line or anorectal junction—dividing the anal canal from the rectum. A hemorrhoid originating above the dentate line (that is, further inside the body) may protrude through the anus to be visible outside the body. Such a hemorrhoid is defined as a prolapsed internal hemorrhoid. Because the area above the dentate line lacks pain receptors, an internal hemorrhoid will cause discomfort only if it is strangulated or incarcerated at the anal opening.
External hemorrhoids originate below the dentate line (outside the body). When external hemorrhoids are acutely swollen or thrombosed, they are more painful than internal hemorrhoids because they are lined with sensitive skin. Physicians are more likely to use a local anesthetic when treating external hemorrhoids.
A mixed hemorrhoid occurs as a confluence of veins from above and below the dentate line merge into a single area of swelling. Hemorrhoids of this type involve prolapsed mucosal tissue, along with the surrounding anoderm (skin).
Physicians should document carefully the exact hemorrhoid type they treat. If the documentation is not clear, ask for additional details. You cannot select an appropriate hemorrhoid treatment code without this information.
Look to Ligation for Internal Treatments
Among treatments for internal hemorrhoids, the most common is simple ligature as described by 46221 Hemorrhoidectomy, by simple ligature (eg, rubber band). Using an anoscope, the physician ligates (ties off) the hemorrhoid at its base, which eliminates the blood supply and causes the swollen vein to shrink over time. Eventually, the remaining tissue and band will slough off and exit with the stool. Only internal hemorrhoids are banded, and the procedure is performed in the office or less commonly in the operating room.
You should report 46221 only once per session, regardless of how many internal hemorrhoids the physician bands. That is, if the physician bands a single hemorrhoid, you would claim a single unit of 46221. If the physician bands three internal hemorrhoids, you would also report one unit of 46221.
Codes 46945 Ligation of internal hemorrhoids; single procedure and 46946 Ligation of internal hemorrhoids; multiple procedures also describe ligation of internal hemorrhoids over one or more sessions. Rather than ligature with a band, these procedures involve ligation of the hemorrhoid(s) with a suture. The surgeon will dictate ligation with a suture, such as a 2-0 Polysorb or Vicryl for instance. This procedure is most frequently performed in the operating room via an anoscope.
Rather than ligature by banding or suture, physicians may choose to inject a sclerosing solution, such as sodium morrhuate, or 5 percent phenol in an oil mixture, into the rectal wall’s submucosa under the internal hemorrhoid. As with ligature, this reduces blood flow and causes the hemorrhoid to shrink. You should code injection of sclerosing solution with 46500 Injection of sclerosing solution, hemorrhoids. You should claim no more than one unit of 46500 per session, regardless of how many injections or hemorrhoids the physician treats by injection.
CPT® 2009 also introduces a new code, 46930 Destruction of internal hemorrhoid(s) by thermal energy (eg, infrared coagulation, cautery, radiofrequency), to describe thermal destruction of one or more hemorrhoids. This method involves burning away the inflamed hemorrhoid tissue using a special probe. Prior to 2009, you would have used now-deleted code 46934 to report this procedure.
For cryosurgery, or destruction of hemorrhoids by freezing, report unlisted procedure code 46999 Unlisted procedure, anus, according to CPT® instructions.
Hemorrhoidopexy Calls for Specific Code
Hemorrhoidopexy, also called procedure for prolapse and hemorrhoids (PPH) (or stapled hemorrhoidectomy), is an alternative surgical procedure to treat prolapsing internal hemorrhoids. The physician performs a progressive anal dilation with an obturator and inserts an anoscope to expose the rectal wall’s circumference. Using a specialized stapling device inserted into the anus, the surgeon removes redundant tissue and staples the rectum’s free mucosal ends together. The stapling device resembles an EEA stapler used for intestinal resections, but it does not remove a full thickness of circular tissue.
You should report hemorrhoidopexy using 46947 Hemorrohodopexy (eg, for prolapsing internal hemorrhoids) by stapling. Limit your claim to a one unit of 46947 per session.
Medicare and other payers typically specify strict coverage requirements to justify reporting 46947. For instance, the physician may have to prove that other treatment methods were previously tried and failed, and Medicare specifically limits hemorrhoidopexy coverage to those prolapsed hemorrhoids of at least Grade III (that is, the hemorrhoid protrudes from the anus during a bowel movement, but can be pushed back into the anus). Check with your individual payer for its requirements prior to claiming 46947.
Thrombosis Affects Procedure Selection
Treatment options for external hemorrhoids vary depending on whether the hemorrhoid has become thrombosed, or clotted. As a rule, thrombosed external hemorrhoids are the most painful of all hemorrhoid types.
When treating a thrombosed external hemorrhoid, the physician has three options:
1. Perform an excision to simultaneously remove the clot and hemorrhoid. For this procedure, you would report one unit of 46320 Enucleation or excision of external thrombotic hemorrhoid for each hemorrhoid/clot the physician treats.
2. Perform an incision and drainage (I&D) to remove the clot only. Often, the hemorrhoid will resolve on its own after clot removal. For this service, you may claim one unit of 46083 Incision of thrombosed hemorrhoid, external for each I&D the physician performs.
3. The thrombosed external hemorrhoid could resolve into a skin tag, at which point the physician may remove it. Skin tags occur below the dentate line, and are usually seen on the outside of the anus. A papilla is very similar to a skin tag, but is located at the dentate line. To report excision of the skin tag, code either 46220 Papillectomy or excision of single tag, anus (separate procedure) or 46230 Excision of external hemorrhoid tags and/or multiple papillae, depending on whether the physician removes a single tag or multiple tags.
If an external hemorrhoid is not thrombosed, the physician may remove it by excision, for which you may report 46250 Hemorrhoidectomy, external, complete. You would claim a single unit of 46250 per session, regardless of how many hemorrhoids the physician treats.
CPT® 2009 eliminated 46935, which previously described removal of external hemorrhoids by any method not described elsewhere. In the unusual case of external hemorrhoids removal by methods other than those covered above (for instance, cryosurgery or thermal energy), you now must report unlisted procedure code 46999.
Mixed Treatments May Include Associated Procedures
When coding for excision of mixed hemorrhoids, you must consider two additional factors:
Complexity. Based on the number and size of hemorrhoids removed, the physician must make a subjective judgment whether to select 46255 Hemorrhoidectomy, internal and external, simple or 46260 Hemorrhoidectomy, internal and external, complex or extensive. As a general rule, single column removal describes a simple procedure, while removal of two or more columns may qualify as complex. When coding for a complex excision, physician documentation should include supporting information to justify the claim.
You should report a single unit of 42655 or 46260 per session, regardless of how many hemorrhoids the physician excises.
Same-Session Procedures. The physician may perform other procedures, such as a fissurectomy, fistulectomy, or fistulotomy, at the same time as mixed hemorrhoids excision. Your coding must adapt to these circumstances.
An anal fissure is a tear in the anal tissue, which may accompany hemorrhoids and can cause severe pain and bleeding. Physicians may treat an anal fissure by excision in a procedure called a fissurectomy.
When a fissurectomy occurs with excision of mixed hemorrhoids, you should report either 46257 Hemorrhoidectomy, internal and external, simple; with fissurectomy or 46261 Hemorrhoidectomy, internal and external, complex or extensive; with fissurectomy, depending on the complexity of the hemorrhoid excision(s).
Occasionally, the physician may also perform fistulectomy to correct an anal fistula, which is an unnatural connection with an internal opening in the anal canal and an external opening in the skin near the anus. An anal fistula can form when an acute anal abscess that’s drained (either on its own or via surgery) doesn’t heal completely and becomes a chronic infection.
When fistulectomy occurs along with excision of mixed hemorrhoids, either with our without fissurectomy, you should select between codes 46258 Hemorrhoidectomy, internal and external, simple; with fistulectomy, with or without fissurectomy and 46262 Hemorrhoidectomy, internal and external, complex or extensive; with fistulectomy, with or without fissurectomy, as appropriate to the complexity of the hemorrhoid excision(s).
For treatment of mixed hemorrhoids by any method other than excision, you should report unlisted procedure code 46999. CPT® deleted destruction by any method internal and external code 46936.
February 1st, 2009