© Copyright 2025 American Medical Association. All rights reserved.
Hemorrhoids are swollen blood vessels located in the anal region, which can be classified into two types: internal and external. Internal hemorrhoids are situated within the anal canal, while external hemorrhoids are found outside the anal opening. The procedure described by CPT® Code 46258 involves a hemorrhoidectomy that addresses both internal and external hemorrhoids, specifically targeting a single column or group of these enlarged vessels. This surgical intervention is often necessary when hemorrhoids cause significant discomfort or complications. In addition to the removal of hemorrhoids, this procedure may also include a fistulectomy, which is the excision of a fistula—a pathological connection between two epithelial surfaces. Furthermore, if an anal fissure, which is a painful tear in the anal mucosa, is present, a fissurectomy may also be performed during this procedure. The combination of these surgical techniques aims to alleviate symptoms and restore normal function in the anal region.
© Copyright 2025 Coding Ahead. All rights reserved.
Hemorrhoidectomy with fistulectomy, as described by CPT® Code 46258, is indicated for patients experiencing significant symptoms related to hemorrhoids, which may include:
The procedure for CPT® Code 46258 involves several key steps, which are detailed as follows:
After the completion of the procedure, patients are typically monitored for any immediate complications. Post-operative care may include pain management, instructions for wound care, and dietary recommendations to promote bowel regularity. Patients are advised to avoid straining during bowel movements and may be prescribed stool softeners to facilitate easier passage. Follow-up appointments are essential to assess healing and address any concerns that may arise during the recovery period.
| Short Descr | REMOVE IN/EX HEM GRP W/FISTU | Medium Descr | HRHC 1 COL/GRP W/FSTULECTMY INCL FSSRECTOMY | Long Descr | Hemorrhoidectomy, internal and external, single column/group; with fistulectomy, including fissurectomy, when performed | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5E - Ambulatory procedures - other | MUE | 1 | CCS Clinical Classification | 81 - Hemorrhoid procedures |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | GC | This service has been performed in part by a resident under the direction of a teaching physician | SG | Ambulatory surgical center (asc) facility service | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2010-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.