In our last article, we addressed the differences between anal fissures and anal fistulas and some of the ways in which these two conditions might be treated by surgeons. We also looked at CPT codes for treatment of a fissure or a fistula by itself (when the surgeon is not treating any other conditions in the rectum/anus during the same surgery). If you have not had an opportunity to review Part 1 of this topic, I would encourage you to do so first as the terminology and definitions we covered will greatly help in understanding the rest of the information presented in this article: https://codingmastery.com/2020/02/02/distinguishing-anal-fissures-from-anal-fistulas/.
Today’s article will focus on CPT codes for treatment of anal fissures and fistulas along with other conditions in the rectum and anus at the same time and provide some example reports that will help you put everything you have learned together and code the treatment of these conditions with confidence.
Anal Fissure Treatment with Hemorrhoidectomy
- 46257: Hemorrhoidectomy, internal and external, single column/group; with fissurectomy
- 46261: Hemorrhoidectomy, internal and external, 2 or more columns/groups; with fissurectomy
These CPT codes are reported when both an anal fissure is excised and hemorrhoids are excised during the same surgery. The code is chosen based on the number of columns/groups of hemorrhoids that are removed. If you need more information about determining the number of columns/groups removed in a hemorrhoidectomy procedure, check out our article about coding hemorrhoidectomy procedures (same principles will apply here with these combination codes): https://codingmastery.com/2018/12/01/successfully-master-coding-hemorrhoid-procedures/.
Anal Fistula Treatment with Hemorrhoidectomy
- 46258: Hemorrhoidectomy, internal and external, single column/group; with fistulectomy, including fissurectomy, when performed
- 46262: Hemorrhoidectomy, internal and external, 2 or more columns/groups; with fistulectomy, including fissurectomy, when performed
These CPT codes are reported when both an anal fistula is excised and hemorrhoids are excised during the same surgery. The code is again chosen based on the number of columns/groups of hemorrhoids that are removed. Notice that these codes also include a fissurectomy “when performed.” That means a fissurectomy is not required to use one of these codes, but you also should not report a fissurectomy separately in addition to these codes if one is performed because the work of performing that fissurectomy is already included in CPT codes 46258 and 46262.
Anal Fistula Treatment with Incision and Drainage
- 46060: Incision and drainage of ischiorectal or intramural abscess, with fistulectomy or fistulotomy, submuscular, with or without placement of a seton.
This CPT code is reported when a specific type of rectal abscess is drained and an anal fistula is either excised or cut open during the same surgery. The specific type of abscess that must be drained to use this code is an ischiorectal abscess (an abscess that forms between the muscles that control the rectum and the pelvic bone) or an intramural abscess (an abscess that forms in the muscular layer of the rectal wall itself). Notice this code also includes placement of a seton when necessary. The phrase “with or without” in CPT means the same thing as “when performed” in code definitions. Therefore, a seton placement is not required to code CPT 46060, but you also wouldn’t code placement of a seton separately in addition to this code if a seton was placed because the work of performing that seton placement is already included in CPT 46060.
Okay now that we have our terminology and codes under our belts, time to put all this together with some chart examples.
Example #1: After sterile prep and drape, an exam under anesthesia was performed. This exam confirmed the presence of an anal fissure with significant inflammation of the surrounding tissue, constricting the anal sphincter. This finding was thought to account for the patient’s recent reports of constipation and significant pain with bowel movements.
Using the Bovie, heat was applied to the fissure and we scraped the tissue to expose the underlying healthy mucosa. We then placed a bougie and stretched the anal sphincter to allow better passage of stool.
The patient tolerated the procedure well. She will be discharged home with instructions to keep the area clean and dry and follow up in our office in 10 days.
Answer Example #1: The bolded portions of the note above are key to accurate code assignment. First we see that the surgeon confirms presence of an anal fissure during an exam under anesthesia. So a “fissure” is the pathology being treated in this case. He also mentions inflammation constricting (narrowing) the anal sphincter. Note that the exam under anesthesia mentioned is bundled to the anorectal procedures performed in this case per the NCCI guidelines.
In paragraph #2, he then tells us what he does to treat the fissure. He first applies heat with a Bovie. A Bovie is a specific type of cautery instrument and applying heat means the same thing as electrocautery. He then scrapes the tissue until healthy tissue is exposed underneath. Scraping is another term for curettage. So he is “destroying” the anal fissure with cautery and curettage. This documentation supports CPT 46940.
Rationale: I recommended CPT 46940 for “initial treatment” since no prior treatment is mentioned. Also the details about having to do an exam under anesthesia to confirm what is accounting for the patient’s symptoms and finding that fissure imply this is initial discovery of the fissure and, therefore, initial treatment as well. Notice, the physician also mentions inserting a bougie (a type of dilator) and stretching/dilating the anal sphincter. Because CPT 46940 includes dilation of the anal sphincter “when performed,” we will not code an additional CPT code for the dilation (it is all part of CPT 46940).
Example 2: After sterile prep and drape, a circumferential anoscopy was performed which appeared to demonstrate internal tract openings in the anus, suspicious for an anal fistula. We then examined the anal opening and saw not one, but two distinct tracts externally. We then inserted a probe into each tract, one at a time, to determine the extent of these tracts. The first tract allowed the probe to pass all the way to the rectum, but the tract did not cross or violate either sphincter, confirming the presence of an extrasphincteric fistula. This tract was fairly small and did not appear to require excision. The second tract allowed passage of the probe to the space between the internal and external sphincters, supporting presence of an intersphincteric fistula. This tract was much more extensive and may require staged treatment.
Beginning with the extrasphincteric fistula, we incised the tract to allow adequate drainage. This concluded our procedure for this first fistula. We then shifted our attention to the much more extensive intersphincteric fistula. The tract was excised to the extent possible, taking care not to violate the sphincters. We then placed a seton to allow for ongoing drainage.
The patient tolerated the procedure well. Given the extent of the second anal fistula, he may require a staged excision or additional seton placement in the coming weeks. He was sent home with discharge instructions and will follow up in the office in 5 days to check status.
Answer Example 2: The bolded portions of the note above are key to accurate code assignment. First we see that the surgeon confirms presence of two distinct anal fistulas during his anoscopy and exam: an extrasphincteric and an intersphincteric fistula. Note that the anoscopy and exam under anesthesia mentioned at the start are bundled to the anorectal procedures performed in this case per the NCCI guidelines.
In paragraph #2, he then tells us what he does to treat the fistulas. He first incises the smaller extrasphincteric fistula (aka a fistulotomy) to allow for adequate drainage. No further work is required on this fistula so he shifts focus to the larger intersphincteric fistula. For this fistula, he excises as much of the fistula tract as he can (aka a fistulectomy) while avoiding injury to the sphincters. He also places a seton. This documentation all together supports CPT 46280.
Rationale: You might initially be tempted to code 46275 for the intersphincteric fistula treatment and 46280 for the extrasphincteric fistula treatment since the term “intersphincteric” does not appear in the code description of CPT 46280. However, what does appear in the code description of CPT 46280 is that the code can be used to report treatment of “multiple fistulas.” Per the description of CPT 46280, those “multiple fistulas” may be treated by a fistulotomy, a fistulectomy, or both. Finally, the description of 46280 also states that this code “includes placement of a seton” when performed. So again the fistulotomy on the extrasphincteric fistula, the fistulectomy on the intersphincteric fistula, and the seton placement in the intersphincteric fistula tract all add up to CPT 46280 since all of that work is described by this one code.
Example 3: After sterile prep and drape, a circumferential anoscopy was performed which demonstrated thrombosed and prolapsing mixed hemorrhoids in the right anterior quadrant. The external hemorrhoid was significantly enlarged due to thrombosis and was actively draining. While this was certainly a significant and somewhat unexpected finding, it does not completely account for the patient’s report of significant pain around the anal sphincter externally. Therefore, we continued our exam and discovered a deep fissure along the left side of the anal opening.
To completely treat these significant findings, we started by circumferentially cutting around the fissure, completely removing this deep groove. We packed the site carefully with sterile gauze to allow for drainage and prevent infection. We then shifted attention to the aforementioned hemorrhoids. The mixed hemorrhoid column was circumferentially excised and bleeding controlled with Bovie.
The patient tolerated the procedure well. We will see him in the office tomorrow to exchange packing material around the fissurectomy site and ensure adequate pain control.
Answer Example 3: The bolded portions of the note above are key to accurate code assignment. First we see that the surgeon confirms presence of mixed hemorrhoids during an anoscopy. As we discussed in our hemorrhoidectomy article, mixed hemorrhoids are hemorrhoids with an internal and external component. These hemorrhoids in this case are in a single column/group in the right anterior quadrant. The surgeon then continues her exam based on the patient’s report of his symptoms and finds a deep anal fissure just outside the anal canal opening. Note that the anoscopy and exam under anesthesia mentioned at the start are bundled to the anorectal procedures performed in this case per the NCCI guidelines.
In paragraph #2, she then tells us what she does to treat the fissure and hemorrhoids. She first cuts all the way around the fissure and “removes the deep groove completely” (aka a fissurectomy). She then goes back to the mixed hemorrhoids and completely excises this single column/group of hemorrhoids which again are internal and external. This documentation all together supports CPT 46257.
Rationale: Because we have a combination code that includes the work of a fissurectomy and excision of a single column/group of internal and external hemorrhoids, all of the work together is reported with CPT 46257. Note that it would be inappropriate to code 46255 (hemorrhoidectomy, internal and external, single column/group) and 46200 (fissurectomy) together instead of using the combination code 46257. Anytime you have a combination code available in CPT that accurately describes the work performed, you should report the combination code instead of two or more codes together to describe the individual procedures.
Example #4: After sterile prep and drape, a circumferential anoscopy was performed which confirmed internal/external hemorrhoids in the right anterior and right posterior positions. We also placed a sterile probe in a tract that began just beyond the anal opening and confirmed extension of that tract across the external sphincter and into the intersphincteric space, thus confirming the suspected transsphincteric fistula.
We began our procedure by lifting the anoderm and circumferential excising the hemorrhoids in the right anterior and right posterior locations. Bleeding was controlled with the Bovie and a couple of sutures placed at each excision site to prevent dehiscence of the tissue. Next we turned our attention to the fistula. We made an incision to open up the fistula tract and allow placement of a seton to facilitate continued drainage.
The patient tolerated the procedure well. He will follow up in the office in a week. If the seton placement and fistulotomy are successful, we will continue to monitor the healing course. If the patient remains symptomatic, he may require an additional surgery for fistulectomy or additional seton placement.
Answer Example #4: The bolded portions of the note above are key to accurate code assignment. First we see that the surgeon discovers internal and external hemorrhoids in two separate groups/columns (right anterior and right posterior). Next, he notices a tract near the anal opening and inserts a probe to see how far that tract extends and where that internal opening is located. He ultimately confirms a transsphincteric anal fistula. Note that the anoscopy mentioned is bundled to the anorectal procedures performed in this case per the NCCI guidelines.
In paragraph #2, he then tells us what he does to treat each condition. He first excises the two columns of hemorrhoids (hemorrhoidectomy, 2 or more columns or groups, internal and external hemorrhoids). We know this is an excision because we see him lifting/elevating the anoderm and “circumferentially excising” the hemorrhoids. He also places a couple of sutures but that is just to control bleeding and keep the tissue at the hemorrhoidectomy site closed (all part of the main procedure). Next, he shifts his focus to the anal fistula and cuts the tract open (fistulotomy) and inserts a seton. This documentation supports CPT 46260 and 46280 together.
Rationale: You might be tempted to code CPT 46262 since the physician is excising hemorrhoids and treating an anal fistula at the same time. But CPT 46262 requires a hemorrhoidectomy of 2 or more columns/groups and a fistulectomy. Here our surgeon performed a fistulotomy not a fistulectomy. For that reason, we would code 46260 for the hemorrhoidectomy of 2 or more internal/external columns/groups and 46280 for a fistulotomy of a transsphincteric fistula with a seton placement together to accurately code this surgery.
Colorectal cases and anorectal surgeries in particular are challenging to code due to the number of different code options and all of the little details that can impact which CPT code(s) would be important. I hope that the terminology and examples presented here help you to code these procedures with confidence. Happy coding!
