Gastroenterology Coding Alert

Gastroenterology practices that bill separately for services that are commonly performed during an endoscopic ultrasound examination (EUS), such as Doppler studies or a celiac nerve block, may be able to boost their payout for the procedure from 10 to 30 percent. This may help combat the lower reimbursement that some gastroenterologists experienced when new EUS codes were added to CPT 2001.
 
For some procedures,  additional EUS codes have made it easier for a gastroenterologist to get appropriate reimbursement. "With a procedure like a rectal EUS, it's a huge advantage to have a specific code," says Lawrence Kim, MD, a gastroenterologist in Englewood, Colo., and a member of the American Gastroenterological Association's Committee on Practice Management and Economics. "Before, we used to bill this as just a diagnostic flexible sigmoidoscopy (45330). Now we get much better reimbursement."
 
The new EUS-guided fine-needle-aspiration codes (FNA), however, were assigned relative value units (RVUs) that were not much higher than the basic EUS examination. CPT 2001's prohibition of reporting radiology code 76975 (gastrointestinal endoscopic ultrasound, supervision and interpretation) with all of the FNA codes meant that in certain situations gastroenterologists would get paid less for performing the additional FNA procedure than if they had performed only the basic EUS examination.
 
An upper gastrointestinal endoscopy (EGD) with EUS (43259), for example, has a Medicare reimbursement of about $298 on an unadjusted basis. The radiological supervision and interpretation code 76975 can also be reported with 43259, which will add another $43. Total payment by Medicare for the procedure will be about $341.
 
On the other hand, when an FNA is performed during the EUS session, the level of reimbursement drops. Code 43242 is used to report the EGD with EUS/FNA, which pays about $299 from Medicare on an unadjusted basis. Unlike 43259, CPT 2001 prohibits billing 76975 with the FNA procedure. Unless other services are billed with the EUS/FNA, the total reimbursement from Medicare will be only $299.
 
This new reimbursement scheme coupled with the fact that an EUS can take much longer and is often riskier than other more highly valued endoscopic procedures leaves many gastroenterologists feeling underpaid. "In my opinion, we will never be reimbursed for an adequate amount for an EUS/FNA, since Medicare and other third-party payers have no clue as to how complex this procedure really is," says Roy Ligresti, MD, director of endoscopic ultrasound at New York Medical College in Valhalla, N.Y.

Reporting Codes for Diagnostic EUS

The first step to ensuring the most reimbursement for these procedures is to use the appropriate EUS code. The basic EUS is reported with three codes:
 

An esophagoscopy with EUS is reported with 43231. This code should only be used in the rare situation of when neither the standard endoscope nor echoendoscope used during the EUS procedure is advanced beyond the esophagus, says Kenneth J. Chang, MD, gastroenterologist, director of the University of California at Irvine Gastrointestinal Oncology Program and Interventional Endoscopy Center. "I almost always go beyond the esophagus and into the stomach," Chang says. "There's usually a reason to look at the liver, adrenal gland or pancreas. If even one endoscope goes beyond the esophagus, an EGD with EUS should be reported."
 
CPT 2001 specifically prohibits 76975 from being billed with 43231.
 

An EGD with EUS is reported with 43259. This code should also be used to report an EUS of the pancreas. Radiological code 76975 can be billed with this procedure.
 

A flexible sigmoidoscopy with EUS is reported as 45341. Code 76975 cannot be billed with 45341. Transrectal echography (76872), another code that gastroenterologists reported in combination with an EUS of the rectum, should no longer be used, Chang says.

A diagnostic endoscopy procedure, such as an EGD (43235) or a flexible sigmoidoscopy (45330), cannot be reported separately with an EUS procedure because the endoscopy is considered part of the EUS.

FNA Codes Also Added

 In addition, CPT added three codes for EUS/FNA:
 

43232 is used to report an esophagoscopy with EUS/FNA. As with its EUS-only counterpart, 43231, this code should be reported when neither endoscope advances past the esophagus. Code 76975 cannot be reported with this code.
 

43242 is used to report an EGD with EUS/FNA. It is also used to report an EUS/FNA of the pancreas. This should be used in place of 48102 (biopsy of pancreas, percutaneous needle), which some gastroenterologists previously used to report an FNA of the pancreas. Code 76975 cannot be reported with this code.
 

45342 is used to report a flexible sigmoidoscopy with EUS/FNA. Code 76975 cannot be reported with this code. Also 76872 should no longer be reported with this code.
 
 
A diagnostic EUS cannot be reported separately with an EUS/FNA code because the EUS is considered part of the EUS/FNA procedure. For example, 45341 cannot be reported in addition to EUS/FNA code 45342.

One controversial way to boost reimbursement that all of the gastroenterologists interviewed for this article are doing is to report a different radiological code, 76942 (ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation), with EUS/FNA procedures. They believe it is a legitimate practice because CPT only addresses the billing of 76975 and makes no reference to other radiological codes. Also Medicare, which pays about $38 for the service, has no edits for the code.
 
"We are billing this code (76942) now and getting paid," Chang says. "My sense, however, is that this code will eventually be eliminated. It is borderline whether you can couple it with the FNA procedure."
 
"We bill it, but it is controversial," says Kim, who adds that his practice does not report the code to those payers who have indicated they will not reimburse separately for any radiological code with an FNA procedure.

Doppler studies performed during an EUS/FNA can also be reported separately. The two Doppler codes that are used the most are 93975 (duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study) and 93976 (... limited study). Reimbursement by Medicare for these is about $96 and $63.
 
One of the problems with this pair of codes is differentiating a complete study (93975) from an incomplete study (93976). "The question is, how does one interpret complete?" Chang says. "If I examine the flow of the portal vein, splenic and mesenteric veins, then Doppler the celiac, splenic and superior mesenteric arteries, I feel I've done a 'complete' study of the abdominal vessels and will code 93975. Most of the time, however, I am usually focusing the Doppler on the portal vein and superior mesenteric artery, and will report the limited study (93976)."
 
Ligresti further clarifies by noting that a complete study needs to report a few fundamental findings such as flow and velocity, while a limited study reports only arterial or venous flow. "Gastroenterologists by and large don't ever do complete Doppler studies of any vessel, as it's beyond the scope of our practice, and best left to cardiologists and vascular surgeons. Most gastroenterologists only want to know if they're about to biopsy the pulmonary artery or a nearby lymph node," he says.
 
One shortcoming to these codes, Chang says, is that they cover only the abdomen and pelvis. If he is doing a Doppler study of the mediastinum, for example, there is no code for Doppler of the chest, and he doesn't report the procedure.
 
Although he uses it rarely, Ligresti would use 93979 (duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; unilateral or limited study) to report a Doppler of the mediastinum or aorta. "There is limited utility for the gastroenterologist in performing a Doppler study in the mediastinum," he explains. "In general, it's used to confirm that what you think is a vessel is in fact a vessel. So on the rare occasion that I use it in the chest, I use the limited-study code 93979."
 
An EUS-guided celiac plexus neurolysis (also referred to as a celiac nerve block) is another procedure that may be separately reported. Chang uses 64680 (destruction by neurolytic agent, celiac plexus, with or without radiologic monitoring) to report this procedure, which has an approximate Medicare reimbursement of $141.

Most gastroenterologists should attach modifier -26 (professional component) to the radiology and Doppler codes (though not the celiac-nerve-block code) mentioned here. These codes contain both a technical component (the value assigned to the ownership and maintenance of the equipment and the use of any technicians) and a professional component (the value assigned to the gastroenterologist's work effort).
 
For a gastroenterologist to be able to bill for the technical component of any diagnostic service, he or she must own (or partially own by being a partner in a practice) the equipment used. When an EUS procedure is performed in a hospital (as it usually is), the hospital gets to bill for the technical component since it owns the equipment, and the gastroenterologist can only bill for the professional component of the radiological or Doppler services. If the gastroenterologist owns the EUS equipment, he or she can bill for both the technical and professional components of the services and no modifier is necessary.