Despite the fact that colonoscopies and certain other gastrointestinal (GI) procedures are all too common, the coding rules for them aren’t exactly simple or straightforward. Here are a few tips to help you avoid the most common GI procedures code mistakes.
Pay attention: Billing for most gastro procedures falls under the endoscopy billing rules for Medicare, according to gastroenterology coding expert Jill Young in her 2019 Coding Updates Virtual Boot Camp for Gastroenterology. And you need to understand how the procedure codes, modifiers, and sometimes diagnoses on your claim form all affect your reimbursement.
Coding Tips: Snare Technique V. Biopsy Forceps
One of the most common mistakes gastro coders make is incorrectly coding colonoscopy procedures involving a biopsy or polyp removal.
If the surgeon uses the cold biopsy forceps method, you should report code 45380 — Colonoscopy, flexible; with biopsy, single or multiple. Report this code only once when the surgeon performs a single biopsy or multiple biopsies of lesions. Also code 45380 once when the surgeon removes portions of a polyp or an entire polyp using cold biopsy forceps.
Crucial: But pay attention to the surgeon’s notes. If the surgeon used the snare technique, you should use code 45385 — Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique. Use this code regardless of whether the surgeon used the “cold” or “hot” snare technique, or the electrosnare method.
Also, be aware of similar coding differences when you’re reporting esophagogastroduodenoscopy (EGD).
For example, review this coding scenario from Next Services: The physician passes an endoscope through the patient’s mouth and into the esophagus, viewing the esophagus, stomach, and duodenum. The physician identifies a polyp in the esophagus and removes it using the snare technique.
How to code: In this case, you would report 43251 — EGD with removal of tumors, polyps or other lesions by snare technique. Do not code 43250 — …by hot biopsy forceps, because doing so will earn you a denial. And even if you don’t get a denial, the reimbursement for 43250 is $40 less than for 43251.
Don’t Separately Bill Control of Bleeding
If you’re coding a biopsy or other endoscopic procedure, you cannot separately bill code 43227 — Esophagoscopy, flexible, transoral; with control of bleeding, any method, according to Outsource Strategies International. That’s because control of bleeding is included in the codes for biopsies and most other endoscopic procedures.
Exception: You can, however, code control of bleeding separately if the patient arrives with a GI bleed and that’s the reason the surgeon performed the endoscopy. You should select the appropriate CPT® code based on the location of the hemo or endo clips the surgeon used to close the wounds and control the bleeding.
Understand the Nuances of Anesthesia Codes
Watch out: For calendar year 2018, you saw CPT® coding changes for certain gastro anesthesia codes and reimbursement.
CPT® deleted codes 00740 (anesthesia for upper GI procedures) and 00810 (anesthesia for lower GI procedures), according to the American Gastroenterological Association, and replaced them with these new codes and base units:
- 00731 — Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified (5 base units)
- 00732 — …endoscopic retrograde cholangiopancreatography (ERCP) (6 base units)
- 00811 — Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified (4 base units)
- 00812 — …screening colonoscopy (3 base units)
- 00813 — Anesthesia for combined upper and lower gastrointestinal endoscopic procedures, endoscope introduced both proximal to and distal to the duodenum (5 base units)
Overall, the 2018 Medicare Physician Fee Schedule reduced the base unit value for screening colonoscopy from 5 to 3, which was a 40-percent reduction that translated into an estimated 28-percent reimbursement decrease, noted Anesthesia Business Consultants.
Bottom line: Make sure you have a solid understanding of how to code gastro procedures, so you will know when you’re not getting paid appropriately, Young stresses. The coding guidelines, including multiple-surgical discounts, can greatly affect the reimbursement you anticipate with a GI procedure. Plus, there are new 2019 CPT® codes waiting just around the corner, so now is the time to get GI procedures codes and endoscopy coding rules right.
