November 11, 2022
From: KarenZupko & Associates, INC, Matthew Twetten, MA, MHCDS

Thank you for the opportunity to review the Electronic Inquiry #13659 and the updated response from AMA Knowledgebase on September 7, 2022. Hemwell has provided KarenZupkoandAssociates with procedure descriptions and redacted operative notes in addition to the previous notes and descriptions.

By way of background, my professional experience includes 18 years as staff for physician specialty societies and as staff liaison to the AMA CPT Editorial Panel. I have authored multiple coding and policy articles for publications such as AAOS Now and SpineLine. I have authored multiple CPT coding applications and presented directly to the CPT Editorial Panel on multiple occasions. I have a Masters in Healthcare Delivery Science from Dartmouth University and Masters of Arts from the State University of New York-Binghamton and I have extensive background with surgical coding and auditing.

Based on a review of relevant clinical publications and illustrations which are shown below as references, my expert opinion is that CPT code 46945, Hemorrhoidectomy, internal, by ligation other than rubber band; single hemorrhoid column/group, without imaging guidance is the most appropriate CPT code to describe the work involved in the procedure done with the Hemwell device. CPT code 46945 describes the destruction of blood supply to the hemorrhoid and does not specify “by suture” or any other method of delivering the ligation beyond noting it is other than rubber band.

Ligation is defined to be the result of the closing off of blood flow to a location. That closure can be achieve by suture, banding, clipping, sealing, etc. The delivery mechanism is not the defining component of the procedure or the work done by a physician in addressing the injury/abnormality requiring correction.

CPT guidance is to use the most similar and appropriate code for a procedure and work involved and my review of CPT codes for hemorrhoid treatment leads me to conclude that CPT 46945 is the most appropriate CPT code for the work done with the Hemwell hemorrhoid device and that other hemorrhoid treatment codes like CPT code 46930, Destruction of internal hemorrhoid(s) by thermal energy (eg, infrared coagulation, cautery, radiofrequency) or 46250, Hemorrhoidectomy, internal and external, single column/group are not correct.

Furthermore, my assessment is that CPT code 46999, Unlisted Procedure, Anus is not appropriate in this instance because 46945 is specific to the work done with the Hemwell device, which is ligation.

Please note that this is my coding advice and interpretation based on the review of the 2022 CPT Professional and the 2022 Medicare Physician Fee Schedule. Our recommendations are made on the basis of materials provided to us by the client and available in CPT Professional and other referenced sources.

If you should have any questions, please feel free to contact me directly or KZA offices and thank you for the opportunity to assist you in your work.

Sincerely,

Matthew Twetten
KarenZupko & Associates Inc