Describe Endoscopy With Scope Type
Question: Last week, the physician performed an endos-copy and took a biopsy of the duodenum to rule out celiac disease in a patient with diarrhea and anemia. Should I report an upper gastroendoscopy code, or do payers consider this procedure a small intestinal endoscopy?
Ohio Subscriber
Answer: The answer depends on what type of scope the physician used during the procedure.
Before sending out the claim, make sure you double-check your code choice with the doctor. You can, however, look at the operative report for clues as to what type of endoscopy took place.
Examine the procedure notes and check for a scope type. If the physician used a pediatric colonoscope or dedicated push enteroscope, this usually indicates a small intestinal endoscopy, in which case you would report 44361 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with biopsy, single or multiple) to describe the procedure, and attach ICD-9 codes 787.91 (Diarrhea) and 783.21 (Loss of weight) to 44361.
If the physician used a standard endoscope, however, she is probably performing an upper GI endoscopy, in which case you would report 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple) for the procedure and codes 787.91 and 783.21 for the diagnoses.
Question: The physician obtained a partial incisional biopsy followed by excision of the same lesion. Should I report the biopsy, the excision, or both?
Oregon Subscriber
Answer: Generally, biopsy is included in excision of the same lesion, but it’s easy to get confused. Follow three basic rules to streamline the process:
1. If the physician performs incisional biopsy on a lesion or lesions, but does not remove any lesions completely, claim only the biopsy(s).
2. If she performs incisional biopsy on a lesion or lesions and follows by excising the remainder of the lesion(s) immediately (as in the case you cite), report only the excision.
3. If the doctor biopsies a lesion but completely excises a different lesion, you may report both the biopsy and lesion codes, as appropriate, with no modifiers, as long as the descriptor for the excision does not include the phrase “with or without biopsy.”
Question: Which code should I report when the physician documents “arthroscopic trephination posterior third medial meniscus”? The doctor says it’s a repair because he uses a trephination needle to rasp the meniscus (which causes it to bleed, so he repairs the tear rather than removes it). Therefore, he thinks we should report 29882, but I think we should append modifier 52 to that code. Is this accurate?
Indiana Subscriber
Answer: No. For this procedure, you should report 29999 (Unlisted procedure, arthroscopy). According to the September 2004 CPT Assistant, “It would not be appropriate to report codes 29882-29883 for the arthroscopic trephination of the meniscus procedure because these codes describe repair performed by a different technique.”
Therefore, you should not bill 29882 (Arthroscopy, knee, surgical; with meniscus repair), with or without modifier 52 (Reduced services), for trephination.
Question: Which code describes MRA of the cranium? We’re having trouble getting reimbursed for this procedure.
Florida Subscriber
Answer: Your options for reporting magnetic resonance angiography (MRA) of the cranium include 70544 (Magnetic resonance angiography, head; without contrast material[s]), 70545 (... with contrast material[s]) and 70546 (... without contrast material[s], followed by contrast material[s] and further sequences). You should select the appropriate code depending on whether the ordering physician specifies the use of contrast materials.
Although MRA is gaining acceptance by payers throughout the country, the number of accepted diagnoses remains small. Common conditions for which the physician orders MRA of the head include nonruptured intracranial aneurysms (437.3, Cerebral aneurysm, nonruptured), arteriovenous malformations or AVM (depending on your payer, you may be able to report 747.81, Other specified anomalies of circulatory system; anomalies of cerebrovascular system or 447.0, Arteriovenous fistula, acquired), and carotid stenosis (433.10, Carotid stenosis, without mention of cerebral infarction).
Question: The physician performed a transbronchial biopsy in the patient’s left upper lobe. He notes that he performed a saline lavage bilaterally and removed all visible secretions from the tracheobronchial tree. Should I report any other services with code 31628?
New York Subscriber
Answer: The details of the “lavage” are very important. If the operative report states that the physician obtained sterile saline washings of the bronchus and sent the washings for culture and cytologic examination, you should consider this procedure as “cell washings.”
Cell washings involve the aspiration of secretions or small amounts of instilled saline from larger airways. Intermediaries consider cell washing as part of the integral service (31622, Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; diagnostic, with or without cell washing [separate procedure]), and you should not report the cell washing separately.
In this case, you can report alveolar lavage (31624) in addition to 31628 (Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with transbronchial lung biopsy[s], single lobe).
Question: We have a patient who comes to the emergency department to receive Procrit injections. His diagnosis is agnogenic myeloid metaplasia (289.89, Other specified diseases of blood and blood-forming organs), which isn’t listed as a payable diagnosis on the Medicare local medical review policy for Procrit. He comes in for the injection weekly. How should I report this? And do I need to give him an advance beneficiary notice?
Kentucky Subscriber
Answer: The first question you need to answer is whether this patient meets the medical-necessity requirements for an evaluation and management service by the physician. One possibility is that the patient may not require an E/M service at all. However, some hospitals have taken the view that all patients presenting to the emergency department require a formal triage process and a medical screening exam (MSE) by the emergency department physician (at minimum). Frequently, hospital legal counsel is involved in guidance regarding these issues. As far as the advance beneficiary notice (ABN) is concerned: Generally, Medicare discourages the issuance of ABNs in the ED. So, if this is indeed an ED patient and you do decide to use an ABN, you should seek legal guidance from the attorney at your facility.
Exception: If the patient presents to the ED because you do not have a separate outpatient injection/infusion services area, and the patient is “scheduled” and registered as an outpatient, then the ED MSE and ABN rules do not apply. In this case, you should obtain an ABN.
--Reader Questions reviewed by Sarah L. Goodman, MBA, CPC-H, CCP, president of SLG Inc. in Raleigh, N.C.
