Gastroenterology Coding Alert

Your claims could get a boost from these placement codes.

If your gastroenterologist performs a high resolution anoscopy (HRA) for screening high risk patients for anal cancers and dysplasia, you'll turn to Category III codes in the CPT® manual to report the services. Read on for our tips on how to apply these codes for HRA reimbursement.

Identify Risk Factors to Support Necessity

Patients may be at high risk for forms of anal dysplasia and cancer, even though they do not have any presenting signs and symptoms. For this purpose, some gastroenterologists have begun the use of high resolution anoscopy to screen high risk patients for early detection of any anal lesions such as dysplasia or cancer.

High risk patients can include those needing special screening for neoplasms due to a personal history or family history, HIV (042, Human immunodeficiency virus (HIV) disease), women or men with human papilloma virus (HPV) related conditions (079.4, Human papillomavirus in conditions classified elsewhere and of unspecified site), and other immune compromised patients.

ICD-9 connection: Your ICD-9 diagnosis code choices for patients that fall into the high risk category, thereby increasing the need for high resolution anoscopy screening, include V76.41 (Screening for malignant neoplasms of the rectum), V76.49 (Special screening for malignant neoplasms other sites) and V76.89 (Special screening for other malignant neoplasms).

Example: You may read that a 69-year-old male patient presents to your gastroenterologist's office with a prior history of neoplasm of the rectum. Although there are no presenting symptoms, your gastroenterologist decides upon screening with HRA to rule out any new lesions.

As your gastroenterologist is only performing this procedure for screening purposes, you can report the procedure with the Category III code 0226T (Anoscopy, high resolution [HRA] [with magnification and chemical agent enhancement]; diagnostic, including collection of specimen[s] by brushing or washing when performed) along with V76.41 to support the need for screening.

Tip: You will need to carefully look through the documentation to check if the HRA was conducted for the sole purpose of screening. The documentation will reflect the patient's high risk status with no predisposing signs and symptoms suggestive of anal dysplasia or cancer.

Switch to 0227T when Biopsy is Performed

If your gastroenterologist finds any suspicious lesions during the procedure and performs a biopsy, then you can report the procedure with 0227T (Anoscopy, high resolution [HRA] [with magnification and chemical agent enhancement); with biopsy[ies]). "The procedure reports of an HRA service may refer to these suspicious lesions as high-grade squamous intra-epithelial lesions (HSIL), Bowen's disease, anal intra-epithelial neoplasia (AIN), or condylomata," says Michael Weinstein, MD, Gastroenterologist at Capital Digestive Care in Washington, D.C., and former representative of the AMA's CPT® Advisory Panel. So, you should look for details like this to support your HRA with biopsy claims.

Example: You may read that a 50-year-old male patient with a prior history of rectal warts presents to your gastroenterologist's practice for routine screening. There are no signs and symptoms suggestive of a neoplasm or any other lesions of the rectum.

However, your gastroenterologist performs HRA to rule out any lesions. During the procedure, your gastroenterologist finds a suspicious lesion and immediately performs a biopsy. Here you will have to report 0227T as the HRA was conducted for screening. You also have to report V76.41 to support your gastroenterologist's intention to perform the HRA.

Caution:You should not get confused between high resolution anoscopy conducted for screening purposes and other anoscopy (46600-46615, Endoscopy procedures on the anus) procedures. Also, you should not report HRA using the closest Category I codes such as 46600 (Anoscopy; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]). You should use 46600 when your gastroenterologist is conducting the anoscopy to diagnose a neoplasm or some type of hemorrhoids that is supported by some presenting signs and symptoms and not when HRA is performed solely for screening.

Reserve Your Reimbursement

"Category III codes are not reviewed by the Relative Value Scale Update Committee (RUC) and do not receive payment valuation," says Weinstein. "They are often considered "experimental" services by insurance carriers and therefore will not be considered a covered benefit. A claim for payment will usually be followed by a denial which can be appealed," he adds.

Even so, CPT® guidelines strictly mandate the utilization of these Category III codes when they are specifically created for the procedure your gastroenterologist has performed, such as high resolution anoscopy. CPT® also specifies that a Category III code should be opted over an unlisted procedure code under Category I.

Ask your payer: While the Medicare national fee schedule has not allocated relative value units (RVUs) to Category III codes, some carriers might still pay for the procedure, so check with your payers.

If you receive a denial, consider an appeal for payment comparing the service to other surgical anoscopic codes and submitting supporting literature about the incidence of anal cancer and the importance of screening.