Gastroenterology Coding Alert

Here’s how to get insurers to pay for 43284.

The standard treatment for GERD (gastroesophageal reflux disease) has long been surgical laparoscopy-- CPT^® 43280 (Laparoscopy, surgical, esophagogastric fundoplasty [e.g., Nissen, Toupet procedures]). However, emerging technologies are introducing alternative procedures and codes that gastroenterology coders and billers must master. This article covers the ins and outs of coding both older and newer treatments for GERD. We’ve also got some tips on how to persuade payers to cough up the cash for the newer treatment.

Reminder: In January 2017, CPT^® replaced two Category III codes (0392T-0393T) with two new codes:

• 43284 (Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie, magnetic band), including cruroplasty when performed)
• 43285 (Removal of esophageal sphincter augmentation device)

Whenever the American Medical Association replaces a Category III codes with a CPT^® code, that’s a strong signal that the new procedure is here to stay. So now, there are essentially two ways to treat GERD. We have the older way — in which a portion of the stomach is surgically wrapped around the gastric fundus to stop reflux — which we code with CPT^® 43280. And we also have the newer way — in which the gastroenterologist laparoscopically inserts magnetic bands around the esophageal sphincter — which we code with CPT^® 43284.

How to Code for Medical Necessity

As a reminder, the following ICD-10 codes are typically linked to GERD procedures.

• K21.0 Gastro-esophageal reflux disease with esophagitis
• K21.9 Gastro-esophageal reflux disease without esophagitis
• K22.70 Barrett’s esophagus without dysplasia
• K22.710 Barrett’s esophagus with low grade dysplasia
• K22.711 Barrett’s esophagus with high grade dysplasia
• K22.719 Barrett’s esophagus with dysplasia, unspecified
• K44.0 Diaphragmatic hernia (includes esophageal hiatus hernia) with obstruction, without gangrene
• K44.1 Diaphragmatic hernia (includes esophageal hiatus hernia) with gangrene
• K44.9 Diaphragmatic hernia (includes esophageal hiatus hernia) without obstruction or gangrene

To avoid errors and denials, make sure everyone in your back office understands that any surgical laparoscopy code always includes diagnostic laparoscopy. That means you should use CPT® 49320 only when it is performed as a separate procedure outside of the actual treatment or surgery.

How to Use CPT^® 43280 & 43284: Different Procedures, Different Codes!

Now that we’ve outlined the coding basics, let’s practice, using these digestive surgery examples:

Coding Scenario #1: A patient underwent a diagnostic laparoscopy and her surgeon identified the GERD condition known as Barrett’s esophagus. After a month on medication with no improvement in her symptoms, the patient received a laparoscopic Nissen procedure to control her reflux.

What to report:

              o 43280 (Laparoscopy, surgical, esophagogastric fundoplasty (eg, Nissen, Toupet procedures) for the Nissen procedure.
              o K21.0 Gastro-esophageal reflux disease with esophagitis

Coding Scenario #2: Patient has been receiving treatment for GERD but has seen no improvement from medication. He decides to proceed with the esophageal sphincter augmentation device procedure because it is less invasive than a traditional laproscopic fundoplasty. The patient displays esophagitis resulting from a hiatal hernia, so the surgeon repairs the hernia with a cruroplasty during the placement of the magnetic band.

What to report

              o 43284 (Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie, magnetic band), including cruroplasty when performed) for the magnetic band placement.
              o DO NOT CODE a separate additional cruroplasty procedure
              o K21.0 Gastro-esophageal reflux disease with esophagitis
              o K44.9 Diaphragmatic hernia (includes esophageal hiatus hernia) without obstruction or gangrene

4 Tips on Getting Paid for 43284

Since the magnetic band augmentation procedure is an up-and-coming treatment for GERD, some insurers might not yet cover it, or may demand you meet strict criteria for reimbursement. Here are some helpful tips to ensure that you can get the optimal reimbursement for the new procedure.

1. Document medical necessity.  Because both fundoplasty and the magnetic band augmentation procedure are surgical interventions for GERD, a provider must demonstrate that the patient has already tried primary measures such as medication and lifestyle changes but received no relief.

2. Be thorough in your reporting. “Since these procedures will have a true CPT^® code, payers should recognize them and assign a reimbursement amount based on provider contract,” says Catherine Brink, BS, CMM, CPC, CMSCS, CPOM, president, Healthcare Resource Management, Inc. Spring Lake, NJ. “I would report these codes based, as always, on the medical record documen­tation to support providing these services to receive optimum reimbursement.” Remember to pay attention to any relevant modification codes for the procedure as well.

3. Provide supporting documentation from FDA. As we mentioned back in January, appending the FDA certificate to the claim can help to persuade a recalcitrant payer.

4. Contact the device manufacturer. With new or unfamiliar medical devices, it can be helpful to contact the manufacturer (for example LINX). “When insurers pay for use of a product, that product becomes easier to market and sell. So, manufacturers will often provide coding advice,” explains John Verhovshek, MA, CPC, managing editor at the American Academy of Professional Coders. Of course, Verhovshek cautions, manufacturer recommendations should only be used as a guideline: “It’s the coder’s professional responsibility to verify any coding suggestions using a confirmed source such as the CPT^® codebook, CPT^® Assistant, instructions from Medicare or the payer in question, etc.”