Gastroenterology Coding Alert

" CPT 2001 includes 14 new gastrointestinal endoscopy codes and several code revisions. The new code additions primarily reflect current endoscopic ultrasound (EUS) examination procedures, ultrasound-guided intramural or transmural fine needle aspiration (FNA)/biopsy procedures and stent placement procedures in most sections of the gastrointestinal tract. While these codes will be welcomed by gastroenterologists, many questions still surround their appropriate usage.

The new gastrointestinal endoscopy codes go into effect on Jan. 1, 2001, and will concentrate on the following three medical procedures:

endoscopic ultrasound examinations (EUS);

ultrasound-guided intramural or transmural fine needle aspiration (FNA)/biopsy; and

the transendoscopic placement of stents.

Coding EUS and FNA/Biopsy

The new EUS and related EUS FNA/biopsy codes are as follows:

43231 esophagoscopy, rigid or flexible; with endoscopic ultrasound examination

43232 ... with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s)

43242 upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s)

45341 sigmoidoscopy, flexible; with endoscopic ultrasound examination

45342 ... with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s)

All CPT definitions for these EUS and FNA/biopsy codes contain the phrase fine needle aspiration/biopsy(s). The (s) indicates that this code should be reported once, regardless of the number of fine needle biopsies taken during the session.

Reimbursement May Drop With New Codes

Although gastroenterologists have lobbied a long time for these EUS codes, they may be disappointed with the reimbursement, particularly from Medicare. A radiological supervision and interpretation code cannot be billed with these new EUS codes. A cross-reference appears at the end of each new EUS and EUS FNA/biopsy code that instructs gastroenterologists to not report 76975 [gastrointestinal endoscopic ultrasound, supervision and interpretation] in conjunction with the EUS procedures.

The CPT manual illustrates that the work that goes into the interpretation and supervision of the radiological films is built into the endoscopic ultrasound codes themselves, says Maurits Wiersema, MD, FACP, FACG, a gastroenterologist and associate professor of medicine at the Mayo Clinic in Rochester, Minn., and a member of the American Medical Associations (AMA) CPT editorial advisory panel.

However, that creates a real paradox because gastroenterologists will get paid less for doing an upper gastrointestinal endoscopy (EGD) with an EUS FNA/biopsy under CPT 2001 than they would if they performed an EGD with only an EUS (43259, upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with endoscopic ultrasound examination) and billed it with the radiological supervision and interpretation code 76975.

Code 43259, to which Wiersema is referring, was the only gastrointestinal EUS code in CPT 2000. In CPT 2001, it is the only EUS code that has a cross reference stating that radiological supervision and interpretation code 76975 may be billed in addition to the EUS procedure.

A gastroenterologist who performs an EGD with an EUS FNA/biopsy will be able to report 43242. Medicare has established a 2001 transitioned facility relative value unit (RVU) of 7.83 for this new code.

On the other hand, a gastroenterologist who performs an EGD only with an EUS examination will be able to report 43259, which has a 2001 transitioned facility RVU of 7.79, and also 76975, which has a 2001 transitioned facility RVU of 2.76. The EGD with EUS examination, while considered the lesser of the two procedures, will receive significantly higher reimbursement than the EGD with EUS FNA/biopsy.

Use of 76942 Questionable

One controversial tactic that some gastroenterologists are thinking of pursuing is to report an additional radiological code with the EUS FNA/biopsy specifically, 76942 (ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device] imaging supervision and interpretation).

There is no CPT cross-reference which says that 76942 cannot be reported, Wiersema explains. And the gastroenterologist will be doing exactly what the code says, using ultrasonic guidance to place a needle.

Not all coding experts agree that this is an appropriate billing combination. The endoscopic code for the EUS guided biopsy/fine needle aspirate includes the work of biopsy, and the reporting of a separate radiological code will not likely be recognized, explains Glenn Littenberg, MD, FACP, a gastroenterologist in Pasadena, Calif., and a member of the AMA CPT editorial panel. I presume, ultimately there will be a CCI edit [for this coding combination.]

There is a lot of confusion over the use of these new EUS codes and the RVUs that have been assigned to them. Gastroenterologists should be aware that further clarification will have to come from CPT or Medicare regarding the use of the alternative ultrasound interpretation code 76942, the RVUs and bundled coding combinations in the CCI to have a definitive resolution to these issues.

New Codes for Stent Placement

The new codes for gastrointestinal endoscopy with stent placement are as follows:

43256 upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transendoscopic stent placement (includes predilation);

44370 small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with transendoscopic stent placement (includes predilation);

44379 small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with transendoscopic stent placement (includes predilation);

44383 illeoscopy, through stoma; with ransendoscopic stent placement (includes predilation);

44397 colonoscopy through stoma; with transendoscopic stent placement (includes predilation);

45327 proctosigmoidoscopy, rigid; with transendoscopic stent placement (includes predilation);

45345 sigmoidoscopy, flexible; with transendoscopic stent placement (includes predilation); and

45387 colonoscopy, flexible, proximal to slenic flexure; with transendoscopic stent placement (includes predilation).

The stenting procedure includes stent insertion, guidewire placement, tumor dilation (predilation with the use of a balloon dilator) and stent deployment. There are still no codes for endoscopy procedures with only dilation in the small intestine or colon.

As with the EUS codes, there are still questions about the use of the new stent placement codes. In a situation where a gastroenterologist places more than one stent within the same portion of the intestine, it is unclear whether the gastroenterologist can report the procedure code twice or whether the stent placement codes cover multiple stents. This question was asked at the November CPT 2001 Coding Symposium in Chicago and the response from the CPT representatives was that the answer was pending approval by the CPT editorial panel.

Code Added for Pseudocyst Drainage

A new code with the following description was added to CPT 2001 for the drainage of a pseudocyst:

43240 upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transmural drainage of pseudocyst.

Code 43240 describes the endoscopically guided drainage of a pseudocyst of the upper gastrointestinal wall and includes the insertion of the drainage tube into the pseudocyst. This procedure will be commonly used in the case of a pancreatic pseudocyst that is in close proximity to the stomach and duodenum. The gastroenterologist will advance the endoscope through the upper gastrointestinal tract, through the stomach and make an incision into the wall of the stomach that is adjacent to the pancreatic pseudocyst.

One question that still has not been answered about this code is whether it includes the placement of the stent across the gastrointestinal wall into the pseudocyst cavity or if that stent placement is separately reportable. Again at the CPT 2001 Coding Symposium, CPT representatives indicated that the answer to that question was still being considered by the CPT editorial panel.

Two New Codes for Gastric Physiology

There are also two new gastric physiology codes in the Medicine section of CPT, which read as follows:

91132 electrogastrography, diagnostic, transcutaneous; and

91133 ... with provocative testing.

These two codes describe the measurement of motility of the stomach in much the same way that esophageal manometry studies (91010, esophageal motility [manometric study of the esophagus and/or gastroesophogeal junction] study;) measure the motility of the lower sphincter esophageal muscles, explains Michael Weinstein, MD, a gastroenterologist in Washington, D.C. and a former member of the AMAs CPT advisory panel. These new codes represent relatively new technologies that are not yet widely performed. Therefore, Medicare has assigned an RVU of 0 and will not reimburse for them.

Additional Code Revisions

In addition to the new codes, there were some revisions to existing codes.

43220 esophagoscopy, rigid or flexible; with balloon dilation (less than 30 mm diameter)

A cross-reference was added to this code which states, If imaging guidance is performed, use 74360. This revision is a clarification that a radiological supervision and interpretation code can be reported if the gastro-enterologist uses fluoroscopy with this procedure.

CPT is in the process of sorting through all these codes where radiological supervision and interpretation may be provided and is adding a cross-reference to indicate when it is and is not appropriate to bill the radiological code, explains Wiersema.

43241 upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transendoscopic intraluminal tube or catheter placement.

The addition of the word intraluminal to this definition is mainly an editorial change to further specify the method of tube or catheter placement.

Changes to Laboratory Tests

There are also a few changes in the Pathology and Laboratory sections of CPT 2001 that are of interest to gastroenterologists. In particular, codes:

83013 Helicobacter pylori; analysis for urease activity (mass spectrometry); and

83014 ... drug administration and sample collection.

Note: For H. pylori, stool, use 87338. For H. pylori, liquid scintillation counter, see 78267, 78268. For H. pylori, enzyme immunoassay, use 87339.

References to the breath specimen that were previously part of 83013 and 83014 have been deleted in order to broaden the use of these codes to include either breath or blood specimens. A cross-reference has been added to indicate other H. pylori laboratory tests.

82270 blood, occult, by peroxidase activity (e.g., guaiac); feces, 1-3 simultaneous determinations.

The description of this code was expanded to allow reporting of assays for the determination of peroxidase activity in hemoglobin.

Although the code changes are effective as of Jan. 1, 2000, there is a three-month grace period before the new codes must be used. Therefore, gastroenterologists should contact their payers to find if and when they plan to adopt the CPT coding changes and update their systems."