Mode of Action
HemWell v Banding
Hemwellectomy is the electrosurgical ligation of the hemorroid’s afferent circulation produce by intense vasospasm of the artierial smooth muscle media and electro-thrombosis. In addition, an electro-biochemical reaction occurs within the serum of the hemorrhoid aiding in it permenent ligation.
46945 (or 46946)- Hemorrhoidectomy, internal by non-thermal ligation other than rubber band; single (or double) hemorrhoid columns/groups.
45330 – Add / If performed in conjunction with a sigmoidoscopy.
45378 – Add / If performed in conjunction with a colonoscopy.

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

 

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Supporting References

1) Garrison, Susan. “2010 CPT Coding Changes Analysis for Gastrointestinal Services in ASCS.” Becker’s ASC Review, 13 June 2011.

2) MacKay, Douglas. “Hemorrhoids and Varicose Veins: A Review of Treatment Options.” Alternative Medicine Review, Apr. 2001.

3) Norman, Daniel. “Direct Current Electrotherapy of Internal Hemorrhoids: An Effective, Safe, and Painless Outpatient Approach.” The American Journal of Gastroenterology, vol. 84, no. 5, May 1989, pp.482-487.

4) Zinberg, Sheldon. “A Personal Experience in Comparing Three Nonoperative Techniques for Treating Internal Hemorrhoids.” The American Journal of Gastroenterology, vol. 84, no. 5, May 1989, pp. 488– 492.

5) Webb, J. C. “THE TREATMENT OF HAEMORRHOIDS BY ELECTROLYSIS.” British Medical Journal, vol. 1, no. 3143, 1921. 6. “Laparoscopic Tubal Ligation or Coagulation.” Laparoscopic Tubal Ligation or Coagulation – Sunnybrook Hospital,

6) “Bipolar and Monopolar Tubal Coagulation Explained.” Laparoscopic Tubal Ligation or Coagulation – Sunnybrook Hospital

7) Fertility Answers, 24 Aug. 2021, Tubal Coagulation – Baton Rouge – Lafayette – Fertility Clinic (fertilityanswers.com)

8) Peshkova AD, Malyasyov DV, Bredikhin RA, Le Minh G, Andrianova IA, Tutwiler V, Nagaswami C, Weisel JW, Litvinov RI. Reduced Contraction of Blood Clots in Venous Thromboembolism Is a Potential Thrombogenic and Embologenic Mechanism. TH Open. 2018 Mar 28;2(1):e104-e115

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