LCD/NCD Portal

L30862

 

DESTRUCTION OF INTERNAL HEMORRHOID(S) BY INFRARED COAGULATION (IRC)

 

06/07/2010

 

Indications and Limitations of Coverage and/or Medical Necessity

 

• The initial conservative treatment for symptomatic hemorrhoids should include dietary management consisting of adequate fluid and fiber intake to relieve constipation and eliminate straining at defecation.

• At least six weeks may be required for significant improvement.

• Conservative treatment should continue even if a procedure is required.

 

 

Indications

• FCSO Medicare will consider infrared coagulation (IRC) medically reasonable and necessary for the treatment of symptomatic Stage I or Stage II internal hemorrhoids that have not responded to conservative treatment.

 

 

Limitations

• IRC is considered useful only in the treatment of Stage 1 and Stage II internal hemorrhoids, without significant prolapse.

 

 

CPT/HCPCS Codes

 

46930 DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG, INFRARED COAGULATION, CAUTERY, RADIOFREQUENCY)

 

 

ICD-9 Codes that Support Medical Necessity

 

455.0 INTERNAL HEMORRHOIDS WITHOUT COMPLICATION

455.1 INTERNAL THROMBOSED HEMORRHOIDS

455.2 INTERNAL HEMORRHOIDS WITH OTHER COMPLICATION

 

 

Documentation Requirements

 

Medical record documentation maintained by the performing provider should include the following, and made available to FCSO Medicare upon request:

• A problem-specific history and physical examination, which should include:

o Information regarding any prior treatments for hemorrhoids and patient’s response.

o The type of conservative treatments utilized and patient’s response.

o The length of time allowed for the resolution of symptoms.

• Results of the physical examination, which should typically include visual inspection of the anus, digital rectal examination and anoscopy.

o Patients with rectal bleeding usually undergo sigmoidoscopy.

o The proximal colon should be evaluated by colonoscopy or air-contrast barium enema to assess bleeding that is not typical of hemorrhoids (e.g., dark blood or blood mixed in the feces), guaiac-positive stools, or anemia.

o The individual patient’s risk factors for colorectal cancer (age, family history, or personal history of polyps) should also be considered when deciding on the extent of colonic evaluation.

• The classification (stage) of the hemorrhoidal disease:

o Stage I - Bleed without prolapse

o Stage II - Prolapse with Valsalva with spontaneous reduction, with or without bleeding

o Stage III - Prolapse with Valsalva requiring manual reduction, with or without bleeding

o Stage IV - Irreducible prolapsed and manual reduction is ineffective

 

 

Utilization Guidelines

• Only one unit of service should be submitted per patient per global period (90 days), regardless of the number of sites treated by infrared coagulation.

o Any subsequent or re-treatment during the 90-day global period should NOT be separately billed.

• It is expected that these services would be performed as indicated by current medical literature and/or standards of practice.

o When services are performed in excess of established parameters, they may be subject to review for medical necessity.

 

 

Treatment Logic:

 

• Hemorrhoids are vascular cushions within the anal canal, usually found in three main locations: left lateral, right anterior, and right posterior portions.

o They lie beneath the epithelial lining of the anal canal and consist of direct arteriovenous communications, mainly between the terminal branches of the superior rectal and superior hemorrhoidal arteries, and, to a lesser extent, between branches originating from the inferior and middle hemorrhoidal arteries and the surrounding connective tissue.

• Hemorrhoids are classified according to their origin; the dentate line (pectinate line) serves as an anatomic-histologic border.

o External hemorrhoids originate distal to the dentate line, arising from the inferior hemorrhoidal plexus, and are lined with modified squamous epithelium, which is richly innervated with somatic pain fibers (delta type, unmyelinated).

o Internal hemorrhoids originate proximal to the dentate line, arising from the superior hemorrhoidal plexus, and are covered with mucosa. Internal hemorrhoids do not have cutaneous innervation and can therefore be destroyed without anesthetic.

o Internal hemorrhoids usually become symptomatic only when they prolapse, become ulcerated, bleed, or thrombose.

• Internal hemorrhoids are further classified into four stages according to the extent of prolapse, as follows:

o Stage I - Bleed without prolapse

o Stage II - Prolapse with Valsalva with spontaneous reduction, with or without bleeding

o Stage III - Prolapse with Valsalva requiring manual reduction, with or without bleeding

o Stage IV - Irreducible prolapsed and manual reduction is ineffective

• Infrared coagulation (IRC) is one of several non-surgical therapies for the treatment of internal hemorrhoids without the need for anesthesia.

o Infrared coagulation involves direct application of infrared waves which penetrates the tissue and converts to heat, promoting coagulation of vessels and fixation of the hemorrhoidal tissue.

o The amount of tissue destruction depends on the intensity and duration of the application. It is recommended that the infrared probe be applied for 1.5 seconds to the apex of each internal hemorrhoid and be repeated three times on each hemorrhoid.

o Infrared coagulation involves direct application of infrared waves resulting in protein necrosis, and is considered useful only in the treatment of Stage 1 and Stage II hemorrhoids, without significant prolapse.

o IRC is associated with high rates of recurrence when substantial prolapse is present.

o Multiple (2-6) hemorrhoids can be treated at one time using IRC.

 

 

Sources of Information and Basis for Decision

 

American Gastroenterological Association medical position statement: Diagnosis and treatment of hemorrhoids. (2004). Gastroenterology, 126(5), 1461-1462. Retrieved December 10, 2009 from www.guideline.gov.

 

Cataldo, et al. The Standards Practice Task Force. The American Society of Colon and Rectal Surgeons. (2005). Practice parameters for the management of hemorrhoids (revised). Dis Colon Rectum, 48, 189-194. Retrieved December 10, 2009 from www.fascrs.org.

 

Kaidar-Person, O., Person, B., & Wexner, S. (2007). Hemorrhoidal Disease: A comprehensive review. J Am Coll Surg, 204(1), 102-117. Retrieved December 11, 2009 from www.mdconsult.com.

 

Society for Surgery of the Alimentary Tract: Surgical management of hemorrhoids. (2008). Retrieved December 10, 2009 from www.ssat.com.

 

06/07/2010

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

 

CMS LCD DESTRUCTION OF INTERNAL HEMORRHOID(S) BY INFRARED COAGULATION (IRC)