Gastroenterology Coding Alert

Tip: Modifier 26 may be your key to separate reimbursement for professional services.

If you thought you might be able to report 76000 or 76001 with an upper GI endoscopy or a proctosigmoidoscopy, the latest edition of the Correct Coding Initiative (CCI) edits should change your mind.

Consider Fluoro Intrinsic to These Gastro Procedures

You have long known that fluoroscopy is included in procedures, such as endoscopic retrograde cholangiopancreatography (ERCP) and gastro tube placements. CCI version 15.3, effective Oct. 1, extends the fluoroscopy bundles to more than 185 codes. You should now include 76000 (Fluoroscopy [separate procedure], up to 1 hour physician time, other than 71023 or 71034 [e.g., cardiac fluoroscopy) and 76001 (Fluoroscopy, physician time more than 1 hour, assisting a nonradiologic physician [e.g., nephrostolithotomy, ERCP, bronchoscopy, transbronchial biopsy) in this partial list of codes:

• Esophagus endoscopy codes 43200-43232

• Upper GI endoscopy codes 43234-43259

• Esophagus lap codes 43279 and 43280

• Stomach lap codes 43644-43653

• Gastric tube codes 43752, 43760, 43761

• Bariatric surgery codes 43770-43774

• Intestinal lap codes 44180-44227

• Small intestine/stomal endoscopy codes 44360-44397

• Surgical appendectomy code 44970

• Proctosigmoidoscopy codes 45300-45327

• Sigmoidoscopy codes 45330-45345

• Colonoscopy codes 45355-45392

• Rectal lap codes 45395-45402

• Anoscopy codes 46600-46615

• Biliary endoscopy codes 47550-47556

• Abdomen, peritoneum, and omentum lap codes 49320-49325

• Lap hernia codes 49650-49657.

What this means: CCI has determined that the fluoroscopy represented by 76000 and 76001 is an intrinsic part of these gastroenterology procedures. You should not bill them separately.

Exception: CCI marks these bundles with modifier indicator "1," meaning that you may be able to report 76000 or 76001 with a modifier appended, under certain clinical circumstances. If the gastroenterologist interprets the fluoroscopy and dictates a radiology report, then you can bill 76000 or 76001 with modifier 26 (Professional component) appended, says Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta.

Both codes 76000 and 76001 are already bundled into ERCP codes 43260-43272 (Endoscopic retrograde cholangiopancreatography [ERCP] ...), biliary lap codes 47560-47570, peritoneal abscess codes 49020-49021, and tube insertion, conversion, and replacement codes 49440-49460.

All these bundles also carry modifier indicator "1."

Silver lining: These edits should not cause much trouble for gastroenterologists in private practice, assures Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel. Some rare inappropriate use of fluoroscopy probably prompted the change, he says. "There are rare circumstances where fluoro is needed to advance an instrument that can't be advanced in the usual manner and where it is clinically necessary to proceed."

Keep ‘Second Physician' in Mind for 99148-99150

You can sum up another aspect of this round of CCI bundles in seven words: Check the edits before reporting moderate sedation.

If you thought CCI left no stone unturned in bundling moderate sedation, think again. CCI version 15.3 continues the trend, bundling 99148-99150 into most other CPT codes. Medicare allows no modifier to separate the bundles.

Roughly 80 percent of the new bundles relate to moderate sedation codes 99148-99150 (Moderate sedation services [other than those services described by codes 00100-01999], provided by a physician other than the health care professional performing the diagnostic or therapeutic service that the sedation supports ...), according to the Sept. 11 "NCCI 15.3 Update" news release by Frank Cohen, MPA, senior analyst with MIT Solutions Inc. in Clearwater, Fla. These edits carry a modifier indicator of "0," which means you can't override the edit with a modifier.

Whether it's lip excisions (40490-40530), omental flaps (49904-49906) or almost any other service in between, CCI edits bundle in various moderate sedation codes. But don't start counting the dollars you'll be losing if the bundled codes are 99148-99150. As the descriptors indicate, these codes describe sedation by a second physician -- not by the physician performing the diagnostic or therapeutic service. So those edits shouldn't change how you code your claims for procedures.

More information: You can download the complete, updated list of CCI bundled codes at www.cms.hhs.gov/NationalCorrectCodInitEd.