Gastroenterology Coding Alert

Remember to keep CCI edits at top of mind when selecting codes.

For some specialties, coding an ablation comes down to one or two choices – but in the gastroenterology field, it can be a lot more complex to pinpoint the most accurate code. Even when you narrow down your options, you’ll have to deal with national Correct Coding Initiative (CCI) bundling issues.

To smooth the path, we’ve rounded up three key tips that will help you nail down the right coding choices from the get-go.

Tip 1: Evaluate the Extent of the Scope

If your gastroenterologist performs an ablation to destroy a tumor or a polyp, you will need to look at the extent to which the physician visualized the upper GI tract using the endoscope. This information will be key to selecting the most accurate code choice.

• In instances when the gastroenterologist performed an ablation and did not extend the scope beyond the esophagus, then you need to report the procedure using 43229 (Esophagoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)).
• If your gastroenterologist visualized the areas of the stomach and beyond the pyloric channel into the duodenum and/or the jejunum, then you need to report the procedure using the code 43270 (Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)).

The most common diagnoses seen in patients requiring ablation procedures include Barrett’s esophagus (K22.7--), and usually in these cases, there will be information in the report mentioning low- or high-grade dysplasia.

In addition, your gastroenterologist may perform these procedures for gastric antral vascular ectasia (GAVE), which is typically reported using K31.819 (Angiodysplasia of stomach and duodenum without bleeding). You may identify ablation procedures for these conditions in reports containing references to Radiofrequency Ablation (RFA) using Barrx devices (for Barrett’s) or Argon Plasma Coagulator (APC) for GAVE or other forms of vascular ectasia, says Glenn  D. Littenberg,  MD,  MACP,  FASGE,  AGAF, a gastroenterologist and former CPT® Editorial Panel member in Pasadena, California. Another technique used for ablation is liquid nitrogen freezing using a small catheter to deliver the chemical to the area being treated.

Heads up: When your gastroenterologist performs esophagoscopic photodynamic therapy (PDT), you will have to report this procedure with either of the add-on codes, +96570 (Photodynamic therapy by endoscopic application of light to ablate abnormal tissue via activation of photosensitive drug(s); first 30 minutes (List separately in addition to code for endoscopy or bronchoscopy procedures of lung and gastrointestinal tract)) or +96571 (…each additional 15 minutes…) along with 43229. 

Note that +96570 and +96571 are selected based on time spent on performing PDT. For 23 to 37 minutes of service, use +96570. For 38 to 52 minutes of service, use +96570 in conjunction with +96571.

Tip 2: Don’t Report Dilation and Guide Wire Use Separately

If you look at the code descriptors for the ablation codes 43229 and 43270, you will notice that they mention the phrase “includes pre- and post-dilation and guide wire passage, when performed.” This informs you that if your clinician had to overcome any obstruction or stricture using guide wire or dilators, you cannot report these procedures separately with 43229 and 43270.

Coding example: Your gastroenterologist performs an upper EGD for a patient suffering from dysphagia, abdominal pain, and bloating. When performing the procedure, your clinician encounters a stricture in the gastroesophageal junction that does not allow the provider to extend the scope further.

Your gastroenterologist then introduces a guide wire through the strictured areas over which he passes a dilator and dilates the stricture to allow the scope to pass through. He then examines the stomach and duodenum. During the examination, he encounters two polyps in the duodenum that he ablates. 

What to report: Since your clinician passed the scope to the stomach and beyond and then performed an ablation, you will report the procedure with 43270. Since the guide wire insertion and dilation are included in the work described by 43270, you will not report 43248 (Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire) separately.

Tip 3: Exercise Caution When Reporting Ablation with Other EGD Procedures

Your physician might perform multiple EGD therapeutics in the same session. When your gastroenterologist performs several procedures, multiple endoscopic payment rules will apply. If your clinician is performing other EGD procedures in the same session in which he performs an ablation, you will also need to pay attention to the CCI edits.

Some of the EGD procedures that run into edits with 43270 include:

• 43250 (Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps)
• 43251 (…with removal of tumor(s), polyp(s), or other lesion(s) by snare technique)
• 43255 (…with control of bleeding, any method)

All the above-mentioned edits carry a modifier indicator of “1,” which means that you can separate the codes with a suitable modifier such as 59 (Distinct procedural service). So if, for example, your gastroenterologist performs removal of a polyp by ablation and removal of another polyp by snare technique in a different location, you can report both 43251 and 43270. You will have to append modifier 59 to 43251.

Caveat: If your clinician ablates a tumor or polyp and, during the procedure, encounters ablation-related bleeding and controls it with a plasma coagulator, then you cannot report 43255 for the bleeding control. In this case, the bleeding control is part of the polyp removal procedure and therefore cannot be reported separately. But if the polyp removal and the bleeding control were in two different sites, you can use the modifier to separate the codes and report them separately. Be sure to provide documentation supporting your claims when you do so.