How To Use CPT Code 46257

CPT 46257 describes the excision of a single internal and external hemorrhoids group, along with the removal of a fissure in the lower rectum. 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 46257?

CPT 46257 can be used to describe the surgical procedure in which a provider removes a single internal and external hemorrhoids group, as well as a fissure in the lower rectum. This code is used when the excision is performed on a patient who has been appropriately prepped and anesthetized.

2. Official Description

The official description of CPT code 46257 is: ‘Hemorrhoidectomy, internal and external, single column/group; with fissurectomy.’

3. Procedure

1. When the patient is appropriately prepped and anesthetized, the provider locates the external hemorrhoid group near the anal canal and the internal portion of the hemorrhoid inside the anus.
2. The provider accesses the hemorrhoid by retracting the anal canal and incises the mucosa around the hemorrhoid column.
3. Next, the provider separates the hemorrhoid from the surrounding tissues and removes it through the anal canal.
4. The provider then incises around the fissure and excises the diseased area.
5. Finally, the operative sites are irrigated with antibiotics and the incisions are closed with sutures or left open for self-healing.

4. Qualifying circumstances

Patients eligible to undergo CPT 46257 are those with a single internal and external hemorrhoids group, along with a fissure in the lower rectum. The procedure is performed on patients who have been appropriately prepped and anesthetized. The provider must ensure that the patient meets the necessary criteria for the excision and removal.

5. When to use CPT code 46257

CPT code 46257 should be used when a provider performs the excision of a single internal and external hemorrhoids group, along with the removal of a fissure in the lower rectum. This code is appropriate when the procedure meets the specific criteria outlined in the official description.

6. Documentation requirements

To support a claim for CPT 46257, the provider must document the following information:

• Patient’s diagnosis and the need for the excision and removal
• Specific details of the procedure, including the location of the hemorrhoid group and the extent of the fissure
• Date and duration of the procedure
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 46257, ensure that the procedure meets the specific criteria outlined in the official description. It is important to accurately report the excision of a single internal and external hemorrhoids group, along with the removal of a fissure in the lower rectum. Pay attention to any additional guidelines or notes provided by the payer to ensure proper billing and reimbursement.

8. Historical information

CPT 46257 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 include the term “simple” in reference to the hemorrhoidectomy.

9. Examples

1. A provider performs a hemorrhoidectomy, removing a single internal and external hemorrhoids group, along with a fissure in the lower rectum.
2. During a surgical procedure, a provider excises a single internal and external hemorrhoids group and performs a fissurectomy in the lower rectum.
3. A patient undergoes a hemorrhoidectomy, with the provider removing a single internal and external hemorrhoids group and addressing a fissure in the lower rectum.
4. As part of a surgical intervention, a provider performs an excision of a single internal and external hemorrhoids group, along with a fissurectomy in the lower rectum.
5. A patient receives treatment for hemorrhoids, with the provider performing a hemorrhoidectomy and removing a single internal and external hemorrhoids group, as well as addressing a fissure in the lower rectum.
6. During a surgical procedure, a provider excises a single internal and external hemorrhoids group and performs a fissurectomy in the lower rectum to alleviate the patient’s symptoms.
7. A patient undergoes a hemorrhoidectomy, with the provider removing a single internal and external hemorrhoids group and addressing a fissure in the lower rectum to improve their condition.
8. As part of a surgical intervention, a provider performs an excision of a single internal and external hemorrhoids group, along with a fissurectomy in the lower rectum, to provide relief to the patient.
9. A provider performs a hemorrhoidectomy, removing a single internal and external hemorrhoids group, as well as addressing a fissure in the lower rectum, to improve the patient’s quality of life.
10. During a surgical procedure, a provider excises a single internal and external hemorrhoids group and performs a fissurectomy in the lower rectum to alleviate the patient’s discomfort and promote healing.