2025 CPT code 46258
Effective Date: N/A Surgery - Surgical Procedures on the Digestive System Surgery Feed
Excision of a single internal and external hemorrhoid group, with fistulectomy and fissurectomy, when performed.
Modifiers may be applicable. Refer to current CPT guidelines for modifier usage.
Medical necessity for this procedure is established by documentation of persistent symptoms despite conservative treatment, significant pain or bleeding, interference with daily activities, or the presence of complications such as thrombosis or infection.
The surgeon is responsible for preparing the patient, administering anesthesia, performing the surgical excision of the hemorrhoids, fistula, and fissure, irrigating the site, and closing the incision.
In simple words: This procedure removes a single cluster of internal and external hemorrhoids along with any associated fistula (abnormal connection) and fissure (tear) in the anal area.The area is cleaned and stitched up or left open to heal naturally.
This procedure involves the surgical removal of a single combined internal and external hemorrhoid group. It also includes the excision of a fistula (an abnormal connection between structures) and a fissure (an open sore in the lower rectum), if present. The procedure begins with the patient being prepped and anesthetized. The surgeon locates the hemorrhoid and makes an incision around it, separating it from the surrounding tissues. The hemorrhoid is then removed, followed by the excision of the fistula and fissure if necessary. The surgical site is then irrigated and closed with sutures or left open to heal.
Example 1: A patient presents with a single, large, combined internal and external hemorrhoid group causing significant pain and discomfort. A fistulectomy and fissurectomy are also performed due to the presence of these conditions., A patient with a thrombosed external hemorrhoid and an associated fistula undergoes this procedure. The internal component of the hemorrhoid is also addressed., A patient has a symptomatic internal hemorrhoid with a co-occurring fissure. This procedure is performed to remove the hemorrhoid and fissure. The absence of a fistula makes fistulectomy unnecessary.
Documentation should include the size and location of the hemorrhoid, the presence and characteristics of the fistula and fissure, the type of anesthesia used, the surgical technique employed, and any complications encountered.
- Revenue Code: P5E (AMBULATORY PROCEDURES - OTHER)
- Specialties:General Surgery, Colon and Rectal Surgery
- Place of Service:Ambulatory Surgical Center, Hospital Outpatient, Inpatient Hospital