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. Lowered RVUs for Stent Placements 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. Fee Amounts for New CPT 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 [...]