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I am having a problem with some claims getting denied when both CPT code 46260 and 45385 are billed together we are using a 59 modifier on the 45385 and BCBS is only paying on 46260 when both these procedures are done on the same day. Should both these codes not be billed together?
I found several things for you. Some of this is not exactly what you need but I feel it will be helpful in the long run. I did find the two codes in the NCCI edits and it appears you can code them together.
No 52, but possibly 59 when only internal hemorrhoids excised
When your surgeon excises an internal hemorrhoid only, don't be tempted to append reduced services modifier 52 to the appropriate "internal and external" hemorrhoid removal code. It's easy to fall into that trap, because CPT does not list any codes specifically for internal hemorrhoid removal only, though it does have some for external removals only. The usual method for routinely removing internal hemorrhoids is not excision but rather banding (46221, hemorrhoidectomy, by simple ligature [e.g., rubber band]) and destruction (46930, destruction of internal hemorrhoid by thermal energy [e.g., infrared coagulation, cautery, radiofrequency]).
On occasion, however, a large internal hemorrhoid may have to be excised. In such cases, says GSCPS Technical Advisor Kathleen Mueller, RN, CPC, CCS-P, general surgery coding consultant, Lenzburg, Ill., the procedure to excise it is much the same as it would be if both an internal and an external hemorrhoid were removed, so the correct code would be one of the following:
46255 (hemorrhoidectomy, internal and external; simple); or
Mueller maintains modifier 52 isn't required for either of these codes when only an internal hemorrhoid is removed, because the procedure is much the same as when both internal and external hemorrhoids are removed. Further, she believes both codes include internal and external excisions "because CPT didn't want surgeons to bill separately for the external hemorrhoid when both internal and external hemorrhoids are removed, not because they wanted to make sure the surgeon also removed an external hemorrhoid." Simple vs. complex: When trying to decide which of the two codes listed above to use, consider factors including the size and number of hemorrhoids. In the end, however, the code choice is subjective and the general surgeon alone decides whether the procedure was simple or complex. But that doesn't mean the surgeon can choose the complex code without documenting why, Mueller says. "Just because it's up to the surgeon doesn't give the surgeon a pass on documentation," she says. "In fact, the size and number of hemorrhoids must be documented in the operative note to support the use of the complex/extensive code." What about hemorrhoids at multiple sites? Anatomically, the anus is divided into quadrants. If the surgeon excises more than one hemorrhoid at different sites (i.e., different anal quadrants), some payers allow you to bill - and will reimburse - each excision separately if you append modifier 59 (distinct procedural service) to the second and any subsequent excision codes, though others will pay for only one excision, regardless of the location of the excised hemorrhoids.
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Typically one code for sphincterotomy, hemorrhoid removal in same session
When the surgeon performs a sphincterotomy to repair an anal fissure and removes one or more hemorrhoids during the same session, you can only report one code. Relatively simple hemorrhoidectomy procedures are bundled with the sphincterotomy, which in turn is bundled with more complicated hemorrhoidectomy procedures. Surgical repair: Report lateral internal sphincterotomy with 46080(sphincterotomy, anal, division of sphincter [separate procedure]). Note the "separate procedure" designation in 46080: If the physician performs 46080 with a related procedure, you cannot report the procedures separately. For example if the surgeon performs 46080 and 46221 (hemorrhoidectomy, by simple ligation, e.g., rubber band) during the same session, you can only report the more extensive procedure - the sphincterotomy. That's because the National Correct Coding Initiative (CCI) bundles 46221 into 46080.
