Codes, payment rates, coverage policy, and whose budget it comes from — internal hemorrhoids office based treatment

1. Summary

This repo's typed hcpcs/payment/coverage/procedures connectors returned unconfirmed for every code probed this pass (46221, 46930, 46945, 46946), each for the same stated reason — no local CMS cache file exists on this machine — which is a structural gap in this environment, not a finding about any code [1]. In its place, a direct fetch of CMS's own CY2026 Physician Fee Schedule "Indicators" data file confirms distinct RVUs, a distinct global-surgery period, and a site-of-service payment differential for four CPT numbers relevant to office-based internal hemorrhoid treatment, and a Federal Register final rule resolves an ambiguity this domain's dossier had left open: CY2026 carries two separate conversion factors, one for qualifying Alternative Payment Model participants and one for everyone else, not two undifferentiated numbers [1][2]. Two independent, non-affiliated commercial payers each publish their own coverage determination for a different office/outpatient hemorrhoid modality — Aetna states infrared coagulation is medically necessary for grade I-II disease, and Anthem Blue Cross Blue Shield states Doppler-guided transanal hemorrhoidal dearterialization is investigational and not medically necessary — but neither is a Medicare determination, and no Medicare NCD/LCD text was retrieved this pass despite a live LCD record being located by search [3][6]. A single manufacturer's own billing guidance is the only source located for two administrative facts this pass could not otherwise confirm from a payer or federal source: a National Correct Coding Initiative bundling relationship, and a HCPCS Level II supply-tray code used alongside banding [4].

2. What Changed

_Baseline (v1). No prior version; this establishes the starting point for future diffs._

3. Details

What this environment could check directly, and what it could not

connectors hcpcs, connectors payment, connectors coverage and connectors procedures each require a local CMS cache file (data/hcpcs_level_ii.csv, data/hcpcs_payment_rates.csv, data/medicare_coverage_policies.csv, data/medicare_procedure_volumes.csv) that is absent on this machine; probing 46221, 46930, 46945 or 46946 through any of the four returns the connector's own missing-file message, never a result about the code. Everything about payment rates below instead comes from a direct fetch of the same primary CMS file this domain's dossier previously located — pfs.data.cms.gov's public metastore, dataset "Indicators for 2026" (identifier 7c7df311-5315-4f38-b9ed-fd62f8bebe11), whose RVU columns implement the methodology set out in 42 CFR 414.22 — retrieved independently this pass [1].

Codes and global periods

Four CPT numbers appear in that file for this domain: 46221, 46930, 46945 and 46946 (code numbers only; descriptor text is AMA-licensed and not reproduced) [1]. The file's global field — a CMS administrative column, not licensed text — shows 46221 carries a 010 (10-day) global-surgery period, while 46930, 46945 and 46946 each carry 090 (90-day) [1]. This is a distinction the domain dossier's existing reimbursement section did not carry (it worked only from 46930/46945/46946 and did not separately locate 46221). A manufacturer's own billing guide independently states the same figure for 46221 — "The ligation (CPT 46221) has a 10 day global period" — so the 10-day global period for 46221 rests on two independent sources and is stated without a marker; the 90-day figures rest on the CMS file alone among sources retrieved this pass [1][4].

Payment rates, resolved against a Federal Register conversion-factor split

The same CMS file carries two rows per code, each tagged to a different conv_fact value (33.4009 and 33.5675) with no distinguishing label in the file itself [1]. The CY2026 Physician Fee Schedule final rule states directly which is which: "We estimate the CY 2026 PFS nonqualifying APM CF to be $33.4009" and, separately, "We estimate the CY 2026 PFS qualifying APM CF to be $33.5675" [2]. Applying total RVU (work + practice expense + malpractice, national unadjusted, no GPCI) × the applicable conversion factor: 46221 pays $325.66 (non-qualifying) or $327.28 (qualifying) non-facility, and $197.07/$198.05 facility; 46930 pays $247.83/$249.07 non-facility and $157.65/$158.44 facility; 46945 and 46946 each carry a single total RVU applied to both settings, paying $350.39/$352.12 and $383.78/$385.69 respectively [1][2]. Locality-adjusted (GPCI-applied) Medicare Administrative Contractor payment will differ from these national-unadjusted figures.

Site-of-service differential

For both codes where CMS prices non-facility and facility settings separately (46221 and 46930), the non-facility (office) total RVU is materially higher than the facility total — $325.66 vs. $197.07 for 46221, $247.83 vs. $157.65 for 46930 at the non-qualifying-APM rate — consistent with CMS pricing more practice-expense RVUs into the code when the physician's own office bears the equipment and staff cost rather than a facility [1][2]. 46945 and 46946 carry a single practice-expense value applied to both settings in this file, i.e., no separate non-facility differential is priced for those two codes [1].

Coverage policy — commercial payers, two different modalities

Aetna's Clinical Policy Bulletin Number 0604 (Infrared Therapy) states it "considers infrared coagulation medically necessary for grade I or grade II internal hemorrhoids that are painful or persistently bleeding," and separately cites CPT 46930 and HCPCS E0221 within its own coding section; the same bulletin does not state a coverage determination for rubber band ligation or sclerotherapy, discussing them only as comparative treatments in its background section [single-source] [3]. Anthem Blue Cross Blue Shield's medical policy (Document #SURG.00141, Publish Date 07/01/2026, Last Review Date 05/14/2026) states plainly: "Doppler-guided transanal hemorrhoidal dearterialization is considered investigational and not medically necessary," and cites CPT 46948 within its own coding section [single-source] [6]. The same policy's background section names a 510(k)-cleared predicate for the underlying device category — "In 2008, the U.S. Food and Drug Administration (FDA) issued a 510(k) approval for the THD Slide system" — which this repo's typed 510k connector confirms independently: K081429, THD SLIDE, decided 2008-07-30 [6]. Read together, the Aetna and Anthem determinations are two independent, non-affiliated payers' own findings for two different modalities, not a shared finding — they are not combined into a single unmarked line. CMS's own file also prices 46948's non-facility and facility RVUs identically (13.34 total both settings, global 090), consistent with a procedure CMS does not expect to be performed in a physician's own office without added facility resources — a data point against, not for, treating dearterialization as directly comparable to this domain's no-sedation office scope [1].

Medicare NCD/LCD — located, not retrieved

An LCD titled "Infrared Coagulation (IRC) of Hemorrhoids" (L34422), administered by Palmetto GBA, and a related Billing and Coding Article, "Hemorrhoid Artery Ligation" (A53006), were both located by search. Neither document's substantive text was retrieved this pass: both URLs returned HTTP 200, but the returned HTML is a JavaScript single-page-application shell containing only generic Medicare Coverage Database help text, not the LCD or Article content itself, which this pass's tools could not reach. No coverage finding from either document is reported here.

NCCI bundling and a HCPCS supply code — manufacturer-sourced only

CRH Medical Corporation's own "Billing Information Sheet" states that diagnostic anoscopy (CPT 46600) and proctoscopy (CPT 45300) are subject to National Correct Coding Initiative bundling when billed with CPT 46221, in the document's own words: "Medicare, along with any other commercial payors that utilize the NCCI edits for reimbursement methodology, will deny the anoscopy and only pay for the ligation" [single-source · manufacturer] [4]. The same document names HCPCS A4550 (Surgical/Supply Tray) as a code sometimes billed alongside banding, and states it "will frequently be denied as included in the main procedure" [single-source · manufacturer] [4]. This pass also directly fetched CMS's own quarterly NCCI additions/deletions/revisions file for the quarter effective 2026-10-01, which lists no change for 46221, 46600, 45300, 46930, 46945 or 46946 — an absence of a new edit this quarter, not a confirmation that any bundling relationship exists or does not, and its filename and version carry no identifier in this report's closed vocabulary, so it is discussed here rather than cited as a numbered source (§5). The full practitioner PTP edit-pair table that would settle the bundling relationship directly is gated behind an AMA license click-through page on cms.gov and was not retrieved (see scope: above).

Whose budget it comes from

Office-based treatment billed under these CPT numbers is paid from Medicare Part B or a commercial payer's own physician fee schedule, per the payment-methodology structure confirmed live via this repo's typed regulation connector against 42 CFR 414.40, which establishes that CMS "establishes uniform national ancillary policies necessary to implement the fee schedule for physician services," naming "global surgery policy" among them [5]. Separately, CRH Medical Corporation's billing guide states that CPT 46221 is generally payable in an Ambulatory Surgical Center facility setting as well as in-office, adding: "TRICARE is the only payor we are aware of that, nationwide, has not allowed the procedure to be performed in a facility as they have not added it to their facility allowed list" [single-source · manufacturer] [4] — a claim about a second federal payer's (TRICARE's) facility policy that this pass could not independently confirm from a TRICARE source.

4. Sources

[1] Physician Fee Schedule, "Indicators for 2026" — Centers for Medicare & Medicaid Services, pfs.data.cms.gov public metastore (modified date not shown in the retrieved metadata record; accessed 2026-09-01). Dataset identifier 7c7df311-5315-4f38-b9ed-fd62f8bebe11; RVU methodology under 42 CFR 414.22; CPT 46221 / 46930 / 46945 / 46946 / 46948 rows — https://pfs.data.cms.gov/sites/default/files/data/indicators2026-07-01-2026.csv [federal-registry] [2] Medicare and Medicaid Programs; CY 2026 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies — Federal Register, Centers for Medicare & Medicaid Services (published 2025-11-05; accessed 2026-09-01), confirmed live via this repo's policy connector. FR Doc No: 2025-19787 (90 FR 49266) — https://www.federalregister.gov/documents/2025/11/05/2025-19787/medicare-and-medicaid-programs-cy-2026-payment-policies-under-the-physician-fee-schedule-and-other [federal-registry] [3] Infrared Therapy — Aetna, Clinical Policy Bulletin Number 0604 (revision date not shown on the retrieved page; accessed 2026-09-01). CPT 46930 and HCPCS E0221 cited within the policy's own coding section — https://www.aetna.com/cpb/medical/data/600_699/0604.html [payer-policy] [4] Billing Information Sheet — CRH Medical Corporation (date not shown on the retrieved page; accessed 2026-09-01). CPT 46221 / HCPCS A4550 cited within the document's own billing-code list — https://physicians.crhsystem.com/wp-content/uploads/Billing_Information_Sheet.pdf [manufacturer] [5] 42 CFR 414.40, Coding and ancillary policies — eCFR, retrieved via this repo's regulation connector (issue 2026-08-13; accessed 2026-09-01). 42 CFR 414.40 — https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-414/subpart-B/section-414.40 [federal-registry] [6] Doppler-Guided Transanal Hemorrhoidal Dearterialization — Anthem Blue Cross Blue Shield (Elevance Health), Medical Policy Document #SURG.00141 (published 2026-07-01; last review 2026-05-14; accessed 2026-09-01). CPT 46948 cited within the policy's own coding section; the policy's background section names the THD Slide 510(k), confirmed via this repo's 510k connector as K081429, decided 2008-07-30 — https://www.anthem.com/medpolicies/abcbs/active/mp_pw_c183647.html [payer-policy]

5. Sourcing & Gaps

Well established: That 46221 carries a 010 global-surgery period rests on two independent, non-affiliated sources — CMS's own CY2026 Indicators file and CRH Medical Corporation's billing guide — and is stated without a marker for that reason [1][4]. That 42 CFR 414.40 and 42 CFR 414.22 exist and say what they are quoted/relied on as saying, that FR Doc 2025-19787 states the two named conversion-factor dollar figures verbatim, and that K081429 is a real 510(k) record for the THD Slide system, all rest on this repo's typed connectors retrieving live data against the eCFR API, the Federal Register API, and openFDA's 510(k) database respectively this pass — class-1 registry checks, not search results [1][2][5][6].

Thin: Aetna's grade I-II infrared-coagulation medical-necessity determination rests on Aetna's bulletin alone [single-source] — no second payer's policy addressing the same modality was located [3]. Anthem's investigational/not-medically-necessary determination for Doppler-guided dearterialization rests on that one policy alone [single-source], and addresses a different modality than Aetna's, so the two are not combinable into one line [6]. The NCCI bundling relationship between CPT 46600/45300 and 46221, and the A4550 supply-tray denial pattern, rest on one manufacturer's billing guide alone [single-source · manufacturer], with no independent payer or federal confirmation retrieved this pass [4]. The TRICARE facility-allowed-list claim rests on the same single manufacturer source [single-source · manufacturer] [4].

Rescoped from class 3: None in this report. Every question addressed here — which code applies, what a named payer's policy states, what a federal regulation or Federal Register rule states, what a manufacturer's own billing guidance claims — is class 1 (a registry record) or a directly quoted class-2/payer-policy/manufacturer document, not a question about what a person would do.

Out of scope: CPT descriptor text throughout, per the manifest's scope note — even where a retrieved source (the CMS Indicators file's sdesc column, Aetna, Anthem, CRH) also carried descriptor-like text, only bare code numbers are reported here. The full CMS NCCI PTP edit-pair table, gated behind an AMA license click-through page (cms.gov/license/ama?file=...), was not retrieved on the same CPT-licensing basis. Non-US coverage policy is out of scope; no connector in this repo queries one.

Not searched vs. not found: Not found — a second commercial payer's coverage determination for infrared coagulation or for Doppler-guided dearterialization specifically, beyond the one payer located for each. Not retrieved, not found-to-be-absent — LCD L34422 and Article A53006: both exist and were located by search, but their document text loads via a client-side mechanism this pass's tools could not reach, distinct from the HTTP 403 seen for other cms.gov pages elsewhere in this fleet. Not text-extractable — a SummaCare "Minimally Invasive Hemorrhoid Procedures Policy" PDF and a Medical Mutual "Laser Hemorrhoidectomy" policy PDF were both fetched as bytes but returned encoded/compressed PDF streams this pass's tools could not render to text; nothing from either is reported. Not searched — Cigna's and UnitedHealthcare's own dedicated hemorrhoid-treatment coverage policies were searched for by name and not located as retrievable documents this pass; Medicaid state-plan coverage was not searched at all. Not carried forward as a numbered source — CMS's quarterly NCCI PTP additions/deletions/revisions file (effective 2026-10-01, directly fetched this pass from www.cms.gov/files/zip/medicare-ncci-2026q4-practitioner-quarterly-additions-deletions-revisions-ptp.zip) confirms no new edit this quarter for any code named in this report, but its filename/version string matches none of this report's closed identifier forms, so it is recorded here rather than as a numbered source (§3).

[inference] The pattern across §3 — a resolved conversion-factor split, a genuine global-period distinction between banding and the other three codes, two payers each addressing a different modality without overlap, and every Medicare-specific coverage document existing but unretrievable — is consistent with (but does not establish) a reimbursement landscape where the federal payment mechanics are now well-documented from primary sources while the coverage-determination layer for this domain specifically remains thin and modality-fragmented across payers. This sentence is the writer's own synthesis of the sourced lines above, not a finding any single source states.

6. Claim Candidates