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Answer: Codes 00740 (anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum) and 00810 (anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum) are no longer paid by Medicare unless there is a valid diagnosis. Some of the acceptable diagnoses (such as polyps or rectal bleeding) can be quite serious and would lead to the patient having more invasive surgery than endoscopy. Medicare will not pay for endoscopies related to diagnoses such as hemorrhoids (ICD-9, 455 and related codes) and diverticulitis (ICD-9, 562 and related codes).
Try to base the claim on the surgeons or gastrointestinal (GI) specialists diagnosis. Use 00810 for small intestine/colon scopes for polyps, unspecified tumors, bleeding, etc., and 00740 for esophageal or upper GI problems such as hiatal hernia, GI bleeding, tumors, foreign bodies, etc. You also could try submitting the claim with modifier -23 (unusual anesthesia) to explain your presence and the use of anesthesia during the procedure. That plus the patients age or other contributing factor should help document the medical necessity. If the paperwork is submitted with a diagnosis such as hemorrhoids that you know Medicare will not reimburse for, look over the operative report to see what the postoperative diagnosis was. You may be able to research the case and find another applicable code you can submit with the procedure and be reimbursed.
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