Author: Kimberly Mansingh

**Updated with new information as of 8/2/2020**

As our understanding of the COVID-19 virus continues to evolve from a clinical perspective, the coding guidance issued by the AHA continues to evolve as well. Changes to the previous guidance provided are in bold and captions with the text **Updated 8/2/2020** to help you spot the new guidelines and get the information you need quickly. AHIMA also has an updated article showing the latest AHA guidance with many different clinical scenarios addressed so I will link you to this great resource as well: https://journal.ahima.org/ahima-and-aha-faq-on-icd-10-cm-coding-for-covid-19/ .

While ICD-10-CM is not the usual focus of content we provide, the novel coronavirus (COVID-19) continues to impact healthcare professionals and facilities across the globe and is impacting daily life for  many of us as well. With all the preparations going on and interruptions to daily life, one impact we may not have considered is the impact this new virus will have for us in our daily coding.

The CDC recently published interim guidelines for coding ICD-10-CM related to the treatment of patients who test positive for COVID-19 and for those who have had a known or suspected exposure and require further testing and workup. While the ICD-10-CM codes for COVID-19 might not be top of mind right now, ensuring that positive cases of COVID-19 and suspected exposure and testing are captured accurately from a coding perspective will ultimately help organizations who track and trend statistics in global health events understand the full impact of this new virus. So with that in mind, we want to dedicate today’s article to the proper coding of COVID-19  from an ICD-10-CM perspective, and provide a few case examples that might help those of you coding services for the treatment of patients impacted by the virus.

ICD-10-CM Codes for Novel Coronavirus (COVID-19):

• For DOS through 3/31/2020: For patients with a confirmed diagnosis of COVID-19 undergoing treatment of conditions related to COVID-19, you will report first the code for the condition being treated (e.g., J80 for acute respiratory distress syndrome) followed by code B97.29: Other coronavirus as the cause of disease classified elsewhere.
• For DOS on or after 4/1/2020: For patients with a confirmed diagnosis of COVID-19 undergoing treatment of conditions related to COVID-19, you will report first the code U07.1: COVID-19 followed by any codes for the condition(s) being treated (e.g., J80 for acute respiratory distress syndrome).
• For patients with confirmed exposure to COVID-19 (e.g., a relative who is positive for the virus) who are undergoing further testing and workup to confirm if they too have COVID-19, report ICD-10-CM code Z20.828: Contact with and (suspected) exposure to other viral communicable diseases.
• For patients with concern about exposure to COVID-19 that is ruled out after further workup, you can report ICD-10-CM code Z03.818: Encounter for observation for suspected exposure to other biological agents ruled out.

Coding Tips for Novel Coronavirus (COVID-19):

• It is really important that we only code B97.29 or U07.1 once the patient has a definitive diagnosis of COVID-19. If the documentation indicates that COVID-19 is “suspected,” “probable,” or uses other similar terms of uncertainty, code the signs/symptoms the patient is being treated for (e.g., fever, shortness of breath, etc.) plus Z20.828 for exposure to COVID-19 if that exposure is supported by the documentation. **Updated 8/2/2020: It is important to note that a physician can clinically confirm that a patient has COVID-19 in their medical records even if the test results are still pending. A physician can also deem that a patient is positive for COVID-19 even if their test is ultimately negative. If a physician diagnosed a patient with COVID-19 while the test results were pending and the test is ultimately negative, though, the physician should be queried to ensure the diagnosis of COVID-19 is still appropriate. If the physician confirms the diagnosis, you may code U07.1 per the latest guidance from AHA.**
• The documentation must support the link between COVID-19 and the condition being treated (e.g., viral pneumonia due to COVID-19) to code the ICD-10-CM code for the condition being treated along with B97.29 or the primary diagnosis U07.1. There is not a presumed cause and effect relationship between respiratory conditions and COVID-19. While patients with more severe cases of COVID-19 are likely to have respiratory conditions as a result, there are many other conditions and organisms (e.g., bacteria) unrelated to COVID-19 that may cause respiratory conditions as well. If documentation is unclear, please query the physician or other qualified healthcare professional. Accurate coding is really important in these cases. **Updated 8/2/2020: Per the AHA, the physician does not need to link the COVID-19 explicitly as the cause of a respiratory condition to code U07.1. The positive test result or the physician’s clinical statement that the patient has COVID-19 is sufficient to code both the U07.1 and the respiratory condition documented.**
• Notice that B97.29 is a code for “cause of disease classified elsewhere.” This means that B97.29 is not a principal or primary diagnosis but instead would be reported secondary to the code for the condition being treated. In contrast, the new code U07.1 which is effective for DOS on or after 4/1/2020 may be reported as a primary ICD-10-CM code.
• **Updated 8/2/2020: Since we are now several months into this pandemic, we are starting to see patients with a history of COVID-19. This history may be important to document and code because the history of COVID may effect patient treatment. Per the AHA, a history of COVID-19 should be coded with Z86.19. If the patient is seen in follow up for a history of COVID-19, you can code both Z09 (follow up) and Z86.19 (for the history of COVID-19) to explain the reason for the encounter. Otherwise, Z86.19 may be used as an additional diagnosis with the primary diagnosis explaining reason for care (e.g., patient presents for surgery for CAD and the physician documents they have a history of COVID-19 but are now asymptomatic and testing negative – you could code I25.10 followed by Z86.19). **
• **Updated 8/2/2020: Finally, we also have some patients with sequela of the disease. Again as we learn more about COVID-19, reports of patients who have been deemed “long-haulers” who are having sequela effects from COVID infection weeks or months prior have emerged. Per the AHA, if a patient presents for treatment of a sequela of COVID-19, code first the condition being treated followed by code B94.8 to capture the sequela COVID-19. While B94.8 is not unique to COVID-19, since COVID-19 is an infectious disease, and we have direct guidance from AHA to use this code for COVID-19 sequelas, adding B94.8 is appropriate.**

Case Examples- Novel Coronavirus (COVID-19):

Example #1: A 56-year-old woman presents to the hospital with a three day history of dry cough, low-grade fever, and respiratory distress. The patient is admitted by the emergency department physician and ultimately tests positive for novel coronavirus . A pulmonologist is then consulted. After obtaining a chest x-ray, the pulmonologist diagnoses the patient with viral pneumonia related to COVID-19 and recommends a treatment plan to the physician who requested the consult. The visit is a level 4 consult. What is the coding for the pulmonologist?

Answer Example #1: CPT code is 99254 (for a level 4 inpatient consult for non-Medicare payers that accept consult codes or 99222 for Medicare or other payers that no longer allow consults). For a DOS on or prior to 3/31/2020, the ICD-10-CM codes for the pulmonologist will be J12.89 (other viral pneumonia) and B97.29 (other coronavirus as the cause of disease classified elsewhere). For a DOS on or after 4/1/2020, the ICD-10-CM codes for the pulmonologist will be U07.1 (COVID-19) and J12.89 (other viral pneumonia). While the patient presents with signs/symptoms, she now has a definitive diagnosis of novel cornavirus (i.e., COVID-19) and was diagnosed during the encounter as having viral pneumonia related to the COVID-19. Because the cause and effect between the viral pneumonia and the COVID-19 is documented, it is appropriate to code the viral pneumonia first followed by the code for COVID-19.

Example #2: A 70-year-old man has been admitted to the hospital for the past 5 days. The admitting physician has already diagnosed him with acute respiratory distress syndrome (ARDS) due to COVID-19, and his respiratory distress continues to worsen. The hospital intensivist performs emergent intubation to support his lungs. No other care other than the intubation is provided by the intensivist. What is the appropriate coding for this scenario?

Answer Example #2: CPT code 31500 would be reported for the emergent intubation. For a DOS on or prior to 3/31/2020, the ICD-10-CM codes for the intensivist will be J80 (acute respiratory distress syndrome) and B97.29 (other coronavirus as the cause of disease classified elsewhere). For a DOS on or after 4/1/2020, the ICD-10-CM codes for the intensivist will be U07.1 (COVID-19) and J80 (acute respiratory distress syndrome). Because the cause and effect between the ARDS and the COVID-19 is documented, it is appropriate to code the ARDS first followed by the code for COVID-19.

Example #3: A 25-year-old male who recently traveled to China with his family presents with a 2 day history of dry cough and a fever of 100.5 degrees Fahrenheit. His father was recently diagnosed with COVID-19 and was also traveling with him. The emergency room physician provides a level 4 ER visit including ordering a chest x-ray to rule out more severe respiratory disease and ordering a test for COVID-19 given the patient’s travel history and proximity to a family member who is positive for the virus. Test results will take another 1-2 days to return. What is the appropriate coding for the ER physician’s work?

Answer Example #3: CPT code is 99284 (for a level 4 emergency room visit). The ICD-10-CM codes for the ER physician will be R05 (cough), R50.9 (fever, unspecified), and Z20.828 (Contact with and (suspected) exposure to other viral communicable diseases).While the patient could certainly have COVID-19 given his recent travel to China and the fact that a close family member already has the disease, his test results are still pending at this time. Remember to only code B97.29 or U07.1 if the diagnosis of COVID-19 is definitive. For now, we should code the signs/symptoms he presented with (the cough and the fever) and his known contact with/exposure to COVID-19 through contact with his dad. **Updated 8/2/2020: The most recent AHA guidance suggests holding the claim for the test results to come back to ensure accurate coding of COVID-related diagnoses. Work with your employer/healthcare institution on the best coding protocols for your patients and specialty.**

To read the CDC’s guidance in its entirety, you can click on the following link: https://www.cdc.gov/nchs/data/icd/ICD-10-CM-Official-Coding-Gudance-Interim-Advice-coronavirus-feb-20-2020.pdf.

If you are coding a tracheostomy procedure (CPT codes 31600-31610), you might be reading your operative report and suddenly see the physician mention the thyroid. This can be confusing at first, and this mention of a completely different organ that feels unrelated to the tracheostomy procedure may leave you feeling like you need to add an additional code for the work performed on the thyroid. However, this work is typically just part of gaining access to the trachea.

To explain, the thyroid isthmus (the cartilage that is in the middle of the thyroid gland and connects the two lobes) is located above the trachea, typically in the vicinity of the 3^rd and 4^th rings. To access the trachea and perform the tracheostomy, surgeons can sometimes retract the thyroid tissue (move it out of the way) without any incision into the trachea. However, when this is not possible, another common approach is to “divide” or “transect” the thyroid isthmus and then move the thyroid out of the way to gain access to the trachea. When a physician divides/transects the trachea, there is no disease or abnormality in the thyroid itself, and no part of the thyroid is actually being removed. The physician is simply dividing the thyroid and moving it out of the way to proceed with the planned procedure on the trachea. In this scenario, the division/transection of the thyroid is part of the approach to the tracheostomy which makes it bundle to the tracheostomy procedure.

To confirm the work on the thyroid is bundled, it is always helpful to look at guidelines from authoritative sources such as CMS and the AMA. In the National Correct Coding Initiative (NCCI) Policy Manual, which is published by CMS and provides guidance about procedures that bundle together, there are some helpful guidelines found in Chapter 1, section B: Coding Based on Standards of Medical/Surgical Practice: “Some procedures are integral in a large number of procedures…examples of procedures that are integral to a large number of procedures include…. Surgical approach including identification of anatomical landmarks, incision, evaluation of the surgical field, debridement of traumatized tissue, lysis of adhesions, and isolation of structures limiting access to the surgical field such as bone, blood vessels, nerve, and muscles including stimulation for identification or monitoring.”

In this example with the thyroid and the trachea, the thyroid must be isolated (or moved out of the way) because it is limiting access to the surgical field (the trachea). Therefore, the work on the thyroid falls under this guideline and is bundled to the tracheostomy since it is part of the surgical approach. Notice that it is how the two procedures relate to each other that make the division/transaction of the thyroid bundled.

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!

Do anal fissures and anal fistulas cause you coding confusion? These two terms sound similar, but refer to different conditions. The treatment of these two conditions is also coded differently. Our article today is dedicated to helping you master the difference between anal fissures and fistulas so you can code the treatment of these conditions confidently.

The information we will cover in this article is very technical (lots of medical terms and anatomy to be familiar with). I’ve included some helpful definitions and links with pictures for those of you who are visual learners. It may take a couple of reads or some additional research (e.g., watching videos) to completely visualize and understand these procedures, but the information presented here should give you a great start.

• An anal fissure is a tear in the lining of the anus or rectum. These tears can occur for a variety of reason, but constipation and passing hard stools are common causes of anal fissures.
• An anal fistula is a tunnel/tract between the anus and the skin around the anus. Again anal fistulas have different causes, but one common cause is an old abscess that did not heal completely. There are many different types of fistulas that are usually named based on their location:

1. Intersphincteric: Inter means between and sphincteric refers to the muscles that control the opening and closing of the anus. There are two sphincters in the human body: one internal and one external. An intersphincteric fistula is one whose tract begins in between the internal and external sphincters and exits typically around the opening of the anus.
2. Extrasphincteric:  Extra means outside or beyond. An extrasphincteric fistula is one whose tract begins in the rectum or sigmoid colon and continues through the levator muscle and ends around the anus. This type of fistula does not involve the sphincters or the space between them, so it is “extra” or “outside” the sphincters.
3. Transsphincteric: Trans means across. A transsphincteric fistula is one whose tract begins in the space in between the internal and external sphincters or in the space behind the anus, comes through/across the external sphincter, and exits within a couple of inches of the anal opening.
4. Suprasphincteric: Supra means “above.” A suprasphincteric fistula is one which begins in the space between the internal and external sphincters and then passes above them (usually taking a route initially above and then through the puborectal muscle and then through the levator ani muscle to exit within a couple of inches of the anal opening).
5. Subcutaneous: This type of fistula sometimes referred to as a “superficial” fistula, is just underneath the surface of the mucosal lining of the rectum in the subcutaneous tissues. It does not involve the sphincters or the inter or suprasphincteric spaces and instead is a more superficial, low-lying fistula.
6. Second Stage: This last term, a “second stage” fistula is actually not referencing a location but a set of conditions under which a fistula is treated. Sometimes with extensive fistulas that involve the sphincters, the surgeon may have to address the problem in two separate operations by opening up/excising part of the fistula in the first operation (first stage) and then opening up/excising the rest of the fistula tract after some healing has occurred in the second operation (second stage).  

If you are more of a visual learner, check out these links which depict the different types of fistulas:

• The first link shows you the anatomy of the anus including the internal and external sphincters and the intersphincteric space (the space between the internal and external sphincters) so you can really visualize where these structures and spaces are located: Anatomy of the Anus
• The second link shows you lines along the anatomy of the anus that depicts the different locations of the fistulas defined above: Types of Anal Fistulas

Now that we have some important anatomy and terms under our belts, let’s start talking about how to code treatment of fissures and fistulas.

Step #1: The first step is to determine if the condition requiring surgery is an anal fissure or an anal fistula. This may sound obvious, but I have seen many times that these two conditions were confused for each other, resulting in a wrong CPT code. Hopefully the definitions above help you determine which condition is appropriate.

Step #2: The next step is to determine the type of surgical procedure performed to treat the condition. Here are some possibilities:

• Surgical Excision: The surgeon may “cut out” the fissure or the fistula tract to remove it completely or in part. When treating a fissure in this way, the surgery is called a fissurectomy. When treating an anal fistula in this way, the surgery is called a fistulectomy.

• Surgical Opening: The surgeon may “cut open” the diseased area to allow the area to drain and heal. This typically happens with a fistula but not a fissure so if a term ending in “otomy” is present in the report, that’s a good sign that you are looking at an anal fistula rather than an anal fissure.

• Closure with Glue: As strange as this may sound, there is a special glue that can be used to close more superficial fissures and fistulas in the anus. This glue is called fibrin glue.

• Closure with Flap: The surgeon may create a small flap of tissue from the surrounding tissue that can be rotated over the fissure or fistula to close it.

• Placement of a Seton: A seton is made of cotton or other absorbable tissue and is passed into the opening and left protruding outside it. The goal is for the fistula to heal around the seton. The seton can then be pulled out or may fall out on its own.

• Destruction: Using cautery (heat) or curettage (scraping) to destroy an anal fissure or fistula.

Below are the established CPT codes available for treatment of anal fissures and anal fistulas when performed as the only anorectal surgical procedure during the case.

.Anal Fissure Treatment

Destruction:

• 46940: Curettage or cautery of anal fissure, including dilation of anal sphincter (separate procedure); initial
• 46942: Curettage or cautery of anal fissure, including dilation of anal sphincter (separate procedure); subsequent

As you can see, there are two codes for “destruction” (i.e., cautery or curettage) of an anal fissure. You choose the code based on whether this is the initial treatment or if this is a subsequent treatment of the same fissure.

Excision

• 46200: Fissurectomy including sphincterotomy, when performed

This code is reported when the anal fissure is excised. A sphincterotomy (cutting the sphincter muscle to allow it to relax/stretch) may also be performed. The sphincterotomy is included in CPT 46200 when performed but is not required to code this CPT.  

Anal Fistula Treatment

Excision or Opening:

• 46270: Surgical treatment of anal fistula (fistulectomy/fistulotomy); subcutaneous
• 46275: Surgical treatment of anal fistula (fistulectomy/fistulotomy); intersphincteric
• 46280: Surgical treatment of anal fistula (fistulectomy/fistulotomy); transsphincteric, suprasphincteric, extrasphincteric, or multiple, including placement of a seton, when performed
• 46285: Surgical treatment of anal fistula (fistulectomy/fistulotomy); second stage

You will recognize a lot of the terms we have already discussed in these code descriptions.

• The first thing to notice is that all of these codes are for “surgical treatment” of the fistula which is defined as a fistulectomy, a fistulotomy, or both.
• The next thing to notice is that the location of the fistula (subcutaneous, intersphincteric, etc.) helps you choose the appropriate code.
• For CPT 46280, this code includes a seton placement “when performed.” So again, if the surgeon places a seton it is included in 46280, but it is not required in order to report this code. For all other types of fistulas not described in CPT 46280 (e.g., subcutaneous, intersphincteric, etc.), you may report both the code for the fistulectomy/fistulotomy plus code 46020 for placement of a seton when both procedures are performed.
• Also, CPT 46280 can be reported for a fistulectomy/fistulotomy of multiple fistulas regardless of what type of fistula is treated (i.e., if the surgeon treats both a transsphincteric and an intersphincteric fistula which would normally fall under different CPT codes when treated by themselves, they would be treating “multiple” fistulas which would be CPT 46280 alone.
• Finally, CPT 46285 is for a “second stage” procedure to treat any type of anal fistula. Again the second stage procedure would be for cases where the same fistula has already been treated partially in a prior procedure and the patient is brought back for a second procedure to complete surgical treatment of the fistula.

Closure with an Anal Flap:

• 46288: Closure of anal fistula with rectal advancement flap

This code is used to report treatment of any type of anal fistula that is closed/repaired with a rectal advancement flap.

Closure with Glue:

• 46706: Repair of anal fistula with fibrin glue

This code is used to report closure/repair of any type of anal fistula with glue. Notice that this code is in a totally different section of CPT than the rest of our anal fistula codes (467xx rather than 462xx). This code emphasizes the importance of good technique when searching for a CPT code (starting with an index search and then looking at the full description in the CPT manual).  This technique ensures you have looked at all of your options and applied the best CPT code to describe the procedure performed. If you went to the 462xx section of CPT alone to start your search, you would miss this code option.

The codes above are for treatment of anal fissures and fistulas by themselves. In our next article we will look at some combination codes that might apply when these conditions are treated along with other conditions of the rectum/anus such as abscesses and hemorrhoids. We will also look at some surgical coding examples to help illustrate how all of these codes might apply to different cases and help you master picking the correct CPT for your particular scenario.