Gastroenterology Coding Alert

Look for your reimbursement to drop as much as 12 percent for some endoscopy procedures because the Centers for Medicare & Medicaid Services hits gastroen-terologists hard with the new Physician Fee Schedule that will be implemented starting March 1, 2003.

"They cut us across the board anywhere from a few dollars up to $20 on some of the procedures," says Lois Curtis, CPC, billing manager, Gastroenterology Associates, Evansville, Ind. The biggest cuts appear in most endoscopies, including EGDs, ERCPs and colonoscopies. CMS has even cut prices on consults and other patient visits, Curtis says. Cuts range from 4 to 5 percent for most cases and are more for certain procedures, such as 43245 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with dilation of gastric outlet for obstruction [e.g., balloon, guide wire, bougie]) at 12 percent. These lowered rates will greatly affect many gastroenterology practices, since many of the patients are Medicare-age. With the soaring costs of doing business and malpractice insurance, the continual decrease in Medicare reimbursement rates could hurt many practices.

Note: All prices are based on the national average rate that is calculated by multiplying the total facility or non-facility RVUs by the conversion factor, 34.5920.

CMS reviewed the physician work required to perform gastrointestinal stent placement services to make sure no "rank-order anomalies" exist in this family of endoscopy codes, according to the Federal Register. The 2003 adjustments evident in the Fee Schedule are interim, since CMS will respond to comments in next-year's final rule.

There are two important changes to the stent placement group. CMS decided that 43256 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transendo-scopic stent placement [includes predilation]) and 44383 (Ileoscopy, through stoma; with transendoscopic stent placement [includes predilation]) are overvalued based on careful review of physician time data. Average payment for the EGD with stent placement will decrease from about $235 to $220, while payment for the ileoscopy with stent placement will fall from about $165 to $155. CMS holds that these changes keep the incremental work value in line with other stent placement codes.

There is one positive note to the fee changes for 2003: the new CPT codes for submucosal injections and dilations, Curtis says. Her practice has been appealing to receive reimbursement for "tattooing" and lower GI dilation procedures for some time and has found no luck when it comes to tattooing, which is included in the submucosal injection codes.

You had to report either an unlisted-procedure code or the base code with modifier -22 (Unusual procedural services) appended, says Margaret Lamb, RHIT, CPC, Great Falls Clinic, Great Falls, Mont. These methods rarely resulted in increased reimbursement. In the new fee schedule, CMS issues work values for these procedures that will enable you to "capture the additional costs and risks associated with these procedures," Lamb says.

For example, the base sigmoidoscopy code (45330) is reimbursed about $98, and the unlisted-procedure code 45999 has a work value of 0. Now, you will use 45335 (Sigmoidoscopy, flexible; with directed submucosal injection[s], any substance) and receive about $135 for nonfacility. That is quite a difference for physicians who perform this procedure regularly.

Other rates for submucosal injection codes include the colonoscopy (45381) at about $365, esophagoscopy (43201) at $230, and upper gastrointestinal endoscopy (43236) at $268 nonfacility.

Another big problem for coders has been lower GI dilation procedures. In the past, there has not been a CPT code for these procedures. Lamb's practice had to bill with an unlisted-procedure code and found reimbursement to be difficult. The new codes will help facilitate payment and lessen the cost of billing. Lamb believes the new rates appropriately reflect the risk and time involved with these procedures. New codes 45340 (Sigmoidoscopy, flexible; with dilation by balloon, 1 or more strictures) and 45386 (Colonoscopy, flexible, proximal to splenic flexure; with dilation by balloon, 1 or more strictures) will be reimbursed about $309 and $695 respectively for non-facility. This compares to the esophagoscopy (43220) and upper GI (43245) endoscopies with dilations that receive about $115 and $596 nonfacility.

CMS definitively reiterates that carriers should not reimburse for conscious sedation. The RUC has considered this issue for some time and has not been able to conclude that there is any incremental physician work associated with conscious sedation.

Physicians have long awaited the formation of codes and fees to represent the new M2ACapsule technology. Gastroenterologists have been using this technology, which allows them to view images of the gastrointestinal tract, for some time now without a definitive way to report it. G0262 (Small intestinal imaging; intraluminal, from ligament of Treitz to the ileo cecal valve, includes physician interpretation and report) ensures accurate reporting of the test. Upon comparisons with other diagnostic tests and their work values, CMS assigned G0262 a facility and nonfacility RVU of 20.87, which equates to about $772 (the professional service brings in about $103). The research assumes that physician work will average 53 minutes. Remember that, until CMS makes an NCD for the service, coverage is at the discretion of carriers and intermediaries.

Another new code, G0272 (Naso/oro gastric tube placement, requiring physician's skill and fluoroscopic guidance [includes fluoroscopy, image documentation and report]), is assigned an RVU of .47 or about $16.

Coders traditionally use G codes only when billing Medicare. However, it is reasonable to use the new G codes on claims to other carriers, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the CPT advisory panel. The result will likely be the same whether you use a G code or an unlisted-procedure code. You will probably need to appeal both claims on paper, so it would be smart for you to approach carriers on a case-by-case basis to get approval to use the new G code to avoid the paperwork.

1. Esophagoscopies (43200-43232) Average cuts range from 5 to 7 percent.

2. Upper gastrointestinal endoscopies (43235-43259) Payment decreased on average from 7 to 12 percent.

3. Endoscopic retrograde cholangiopancreatography (43260-43272) Average cut of 5 percent.

4. Sigmoidoscopies (45330-45345) Price decreases from 7 to 12 percent.

5. Colonoscopies (45378-45387) Average rate cuts from 8 to 11 percent.

6. Evaluation and management services Expect a consistent decrease in reimbursement by 3 to 5 percent.