How To Use CPT Code 46258

CPT 46258 describes the excision of a single internal and external hemorrhoid group, along with a fistulectomy and fissurectomy if necessary. 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 46258?

CPT 46258 can be used to describe the surgical procedure in which a healthcare provider removes a single internal and external hemorrhoid group. Additionally, the provider may perform a fistulectomy, which involves removing an abnormal connection between structures, and a fissurectomy, which involves removing an open sore in the lower rectum known as a fissure.

2. Official Description

The official description of CPT code 46258 is: ‘Hemorrhoidectomy, internal and external, single column/group; with fistulectomy, including fissurectomy, when performed.’

3. Procedure

1. After appropriate preparation and anesthesia, the healthcare provider locates the external hemorrhoid near the anal canal and the internal portion of the hemorrhoid inside the anus.
2. By retracting the anal canal, the provider gains access to the hemorrhoid.
3. The provider then incises the mucosa around the hemorrhoid column and separates the hemorrhoid from the surrounding tissues.
4. The hemorrhoid is carefully removed through the anal canal.
5. If a fistula is present, the provider incises around it and excises the diseased area.
6. If a fissure is present, the provider may also incise around it and remove it.
7. The operative sites are irrigated with antibiotics, and the incisions are closed with sutures or left open for self-healing.

4. Qualifying circumstances

CPT 46258 is performed on patients with internal and external hemorrhoids, as well as those with a fistula or fissure that requires surgical intervention. The procedure is typically performed by a healthcare provider who is experienced in performing hemorrhoidectomies and related procedures.

5. When to use CPT code 46258

CPT code 46258 should be used when a healthcare provider performs a hemorrhoidectomy on a patient with a single internal and external hemorrhoid group. The code also covers the additional procedures of fistulectomy and fissurectomy, if performed during the same surgical session.

6. Documentation requirements

To support a claim for CPT 46258, the healthcare provider must document the following information:

• Patient’s diagnosis of internal and external hemorrhoids, fistula, and/or fissure
• Description of the surgical procedure performed, including the excision of the hemorrhoid group, fistulectomy, and fissurectomy
• Date of the procedure
• Details of the incisions made and closure method used
• Any complications or additional procedures performed
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 46258, ensure that the procedure meets the criteria outlined in the official description. It is important to accurately document the specific procedures performed, including the excision of the hemorrhoid group, fistulectomy, and fissurectomy. Additionally, follow any specific billing guidelines provided by the payer to ensure proper reimbursement.

8. Historical information

CPT 46258 was added to the Current Procedural Terminology system on January 1, 1990. On January 1, 2010, the code description was changed to include the option of performing a fissurectomy along with the hemorrhoidectomy and fistulectomy.

9. Examples

1. A healthcare provider performs a hemorrhoidectomy, fistulectomy, and fissurectomy on a patient with a single internal and external hemorrhoid group.
2. During a surgical procedure, a provider excises a single internal and external hemorrhoid group and performs a fistulectomy.
3. A patient undergoes a hemorrhoidectomy, along with a fistulectomy and fissurectomy, to address their hemorrhoids, fistula, and fissure.
4. A healthcare provider performs a hemorrhoidectomy and fistulectomy on a patient with a single internal and external hemorrhoid group and a fistula.
5. During a surgical procedure, a provider removes a single internal and external hemorrhoid group and performs a fissurectomy to address the patient’s hemorrhoids and fissure.
6. A patient undergoes a hemorrhoidectomy, along with a fistulectomy and fissurectomy, to address their hemorrhoids, fistula, and fissure.
7. A healthcare provider performs a hemorrhoidectomy and fistulectomy on a patient with a single internal and external hemorrhoid group and a fistula.
8. During a surgical procedure, a provider removes a single internal and external hemorrhoid group and performs a fissurectomy to address the patient’s hemorrhoids and fissure.
9. A patient undergoes a hemorrhoidectomy, along with a fistulectomy and fissurectomy, to address their hemorrhoids, fistula, and fissure.
10. A healthcare provider performs a hemorrhoidectomy and fistulectomy on a patient with a single internal and external hemorrhoid group and a fistula.