CAM 70126

Infrared Coagulation for Hemorrhoids

Category:Surgery   Last Reviewed:March 2019
Department(s):Medical Affairs   Next Review:March 2999
Original Date:March 1996    

Description:
Infrared coagulation, also called photocoagulation, is used to treat symptomatic first- and second-degree internal hemorrhoids. Pulses of infrared radiation are applied to the hemorrhoidal base through a hand-held applicator. These pulses produce a discrete area of necrosis, which heals to form a scar. This reduces or eliminates blood flow through the hemorrhoid, thereby shrinking it, and the mucosa becomes fixed to the underlying tissue. The procedure is easily performed in a physician’s office.


The diagnosis of internal and external hemorrhoids is made by inspection, digital examination and direct vision through the anoscope and proctoscope. Whenever the internal hemorrhoidal plexus is enlarged, there is an associated increase in supporting mass and the resultant venus swelling is called an internal hemorrhoid. When veins in the external hemorrhoidal plexus become enlarged, the resultant bluish mass is called an external hemorrhoid. External hemorrhoids require an incision because they are below the skin.

Policy:
Infrared coagulation is considered MEDICALLY NECESSARY for:

  • Persistent bleeding
  • Painful first- and second-degree internal hemorrhoids 

Payment may be considered for a maximum of four treatments within a six-month period.

References:

  1. Christopher Hess. WebMD Medical Reference from Healthwise. Infrared photocoagulation for hemorrhoids. Last updated November 10, 2004.
  2. Accarpio G, Ballari F, Puglisi R, e al. Outpatient treatment of hemorrhoids with a combined technique: Results in 7850 cases. Tech Coloproctol. 2002;6(3):195-196.
  3. Gupta PJ. Infrared coagulation versus rubber band ligation in early stage hemorrhoids. Braz J Med Biol Res. 2003;36(10):1433-1439.
  4. Madoff RD, Fleshman JW; Clinical Practice Committee, American Gastroenterological Association. American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids. Gastroenterology. 2004;126(5):1463-1473 

Coding Section

Codes Number Description
CPT 46930 Destruction of internal hemorrhoid(s) by thermal energy (e.g., infrared coagulation, cautery, radiofrequency) (new code 1/1/09)
  46934 Destruction of hemorrhoids, any method; internal (code deleted 12/31/08)
ICD-9 Procedure 49.49 Other procedures on hemorrhoids
ICD-9 Diagnosis 450.0-455.1 Internal hemorrhoids code range
   

Note: ICD-9 does not classify hemorrhoids by degrees.
Below are narratives for each code.
455.0 Internal hemorrhoids without complication
455.1 Internal thromboses hemorrhoids

HCPCS No Code  
ICD-10-CM (effective 10/01/15)  I8000 Phlebitis and thrombophlebitis of superficial vessels of unspecified lower extremity 
  I8010  Phlebitis and thrombophlebitis of unspecified femoral vein
  I80209  Phlebitis and thrombophlebitis of unspecified deep vessels of unspecified lower extremity 
  I803  Phlebitis and thrombophlebitis of lower extremities, unspecified 
  I80219  Phlebitis and thrombophlebitis of unspecified iliac vein 
  I808  Phlebitis and thrombophlebitis of other sites 
  I809  Phlebitis and thrombophlebitis of unspecified site 
  I81  Portal vein thrombosis 
  I820  Budd-Chiari syndrome 
  I821  Thrombophlebitis migrans 
  I82220  Acute embolism and thrombosis of inferior vena cava 
  I82221  Chronic embolism and thrombosis of inferior vena cava 
  I823  Embolism and thrombosis of renal vein 
  I82409  Acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity 
  I82429  Acute embolism and thrombosis of unspecified iliac vein 
  I82439  Acute embolism and thrombosis of unspecified popliteal vein 
  I824Y9  Acute embolism and thrombosis of unspecified deep veins of unspecified proximal lower extremity 
  I82449  Acute embolism and thrombosis of unspecified tibial vein 
  I82499 Acute embolism and thrombosis of other specified deep vein of unspecified lower extremity 
  I824Z9  Acute embolism and thrombosis of unspecified deep veins of unspecified distal lower extremity 
  I82509  Chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity 
  I82599  Chronic embolism and thrombosis of other specified deep vein of unspecified lower extremity 
  I82519  Chronic embolism and thrombosis of unspecified femoral vein 
  I82529  Chronic embolism and thrombosis of unspecified iliac vein 
  I82539  Chronic embolism and thrombosis of unspecified popliteal vein 
  I825Y9  Chronic embolism and thrombosis of unspecified deep veins of unspecified proximal lower extremity 
  I82549  Chronic embolism and thrombosis of unspecified tibial vein 
  I825Z9  Chronic embolism and thrombosis of unspecified deep veins of unspecified distal lower extremity 
  I82819  Embolism and thrombosis of superficial veins of unspecified lower extremities 
  I82719  Chronic embolism and thrombosis of superficial veins of unspecified upper extremity 
  I82729  Chronic embolism and thrombosis of deep veins of unspecified upper extremity 
  I82709  Chronic embolism and thrombosis of unspecified veins of unspecified upper extremity 
  I82A29  Chronic embolism and thrombosis of unspecified axillary vein 
  I82B29  Chronic embolism and thrombosis of unspecified subclavian vein 
  I82C29  Chronic embolism and thrombosis of unspecified internal jugular vein 
  I82291  Chronic embolism and thrombosis of other thoracic veins 
  I82891  Chronic embolism and thrombosis of other thoracic veins 
  I82619  Acute embolism and thrombosis of superficial veins of unspecified upper extremity 
  I82629  Acute embolism and thrombosis of deep veins of unspecified upper extremity 
  I82609  Acute embolism and thrombosis of unspecified veins of unspecified upper extremity 
  I82A19  Acute embolism and thrombosis of unspecified axillary vein 
  I82B19  Acute embolism and thrombosis of unspecified subclavian vein 
  I82C19  Acute embolism and thrombosis of unspecified internal jugular vein 
  I82290  Acute embolism and thrombosis of other thoracic veins 
  I82890  Acute embolism and thrombosis of other specified veins 
  I8291  Chronic embolism and thrombosis of unspecified vein 
  I83009  Varicose veins of unspecified lower extremity with ulcer of unspecified site 
  I83019  Varicose veins of right lower extremity with ulcer of unspecified site 
  I83029  Varicose veins of left lower extremity with ulcer of unspecified site 
  I8310  Varicose veins of unspecified lower extremity with inflammation 
  I83209  Varicose veins of unspecified lower extremity with both ulcer of unspecified site and inflammation 
  I83899  Varicose veins of unspecified lower extremities with other complications 
  I8390  Asymptomatic varicose veins of unspecified lower extremity 
  K648  Other hemorrhoids 
ICD-10-PCS (effective 10/01/15)  0D7Q7ZZ Dilation of Anus, Via Natural or Artificial Opening
  0D7Q8ZZ Dilation of Anus, Via Natural or Artificial Opening Endoscopic
Type of Service Surgery  
Place of Service Outpatient/Phsician's Office  

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

03/04/2019 

Annual review, no change to policy intent. 

03/19/2018 

Annual Review. No change to policy intent 

03/02/2017 

Annual review.  No change to policy intent 

03/08/2016 

Annual review. No change to policy intent.  

09/23/2015 

Added ICD-10 coding to policy. 

03/05/2015 

Annual review. No change to policy intent. Added coding.

03/4/2014

Annual review. No changes made.


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