How To Use CPT Code 46255

CPT 46255 describes the excision of a single internal and external hemorrhoid or hemorrhoid group. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 46255?

CPT 46255 can be used to describe the surgical procedure of removing a single internal and external hemorrhoid or hemorrhoid group. This code is used when the provider excises the hemorrhoid(s) located near the anal canal and inside the anus. The procedure involves incising the mucosa around the hemorrhoid column, separating the hemorrhoid from surrounding tissues, and removing it through the anal canal. The provider may close the incision with sutures or leave it open for self-healing of the wound.

2. Official Description

The official description of CPT code 46255 is: ‘Hemorrhoidectomy, internal and external, single column/group.’

3. Procedure

1. After appropriate patient preparation and anesthesia, the provider identifies the external hemorrhoid near the anal canal and the internal hemorrhoid inside the anus.
2. The provider accesses the hemorrhoids by retracting the anal canal.
3. Next, the provider incises the mucosa around the hemorrhoid column and separates the hemorrhoid from surrounding tissues.
4. The hemorrhoid is then taken out through the anal canal.
5. The provider controls bleeding from the excision site and irrigates the area with antibiotics.
6. The incision may be closed with sutures or left open for self-healing of the wound.

4. Qualifying circumstances

CPT 46255 is performed on patients with internal and external hemorrhoids that require surgical removal. The procedure is typically done when other conservative treatments have failed to provide relief. The patient must be appropriately prepped and anesthetized for the procedure. The provider must accurately locate and identify the hemorrhoids near the anal canal and inside the anus.

5. When to use CPT code 46255

CPT code 46255 should be used when a provider performs the excision of a single internal and external hemorrhoid or hemorrhoid group. It is important to note that this code is not appropriate for the excision of only an external hemorrhoid. In such cases, code 46999, Unlisted procedure, anus, should be reported instead.

6. Documentation requirements

To support a claim for CPT 46255, the provider must document the following information:

• Patient’s diagnosis indicating the presence of internal and external hemorrhoids
• Details of the procedure, including the location of the hemorrhoids and the approach used
• Description of any complications or additional procedures performed
• Documentation of anesthesia administration, if applicable
• Post-operative care instructions and any prescribed medications
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 46255, ensure that the procedure involves the excision of a single internal and external hemorrhoid or hemorrhoid group. It is important to accurately code the procedure and not report it as an unlisted procedure unless it meets the criteria for an unlisted code. Additionally, consider any applicable modifiers or additional services provided during the same encounter.

8. Historical information

CPT 46255 was added to the Current Procedural Terminology system on January 1, 1990. The code underwent a change on January 1, 2010, with the description being updated to ‘Hemorrhoidectomy, internal and external, simple.’

9. Examples

1. A provider performs the excision of a single internal and external hemorrhoid for a patient with recurrent hemorrhoidal symptoms.
2. A patient undergoes the surgical removal of a hemorrhoid group consisting of multiple internal and external hemorrhoids.
3. A provider performs a hemorrhoidectomy on a patient with severe hemorrhoidal bleeding and prolapse.
4. A patient with chronic hemorrhoidal pain undergoes the excision of a single internal and external hemorrhoid.
5. A provider performs a hemorrhoidectomy on a patient with thrombosed external hemorrhoids causing significant discomfort.
6. A patient undergoes the surgical removal of a single internal and external hemorrhoid that has not responded to conservative treatments.
7. A provider performs a hemorrhoidectomy on a patient with internal and external hemorrhoids causing recurrent anal itching and discomfort.
8. A patient with a history of hemorrhoidal thrombosis undergoes the excision of a single internal and external hemorrhoid.
9. A provider performs a hemorrhoidectomy on a patient with internal and external hemorrhoids causing significant bleeding during bowel movements.
10. A patient undergoes the surgical removal of a hemorrhoid group consisting of multiple internal and external hemorrhoids causing chronic pain and discomfort.