Gastroenterology Coding Alert

And watch these chemodenervation bundles.

If you're reporting duodenal intubations with upper GI endoscopies, you will need to apply the brakes, thanks to the latest version of the Correct Coding Initiative (CCI) edits -- Version 18.2 that came into effect July 1, 2012. Read on for details on how the new set of edits will affect reporting these procedures together.

Overview: The CCI released version 18.2, effective July 1, 2012, revealing 2,521 new active pairs and 88 code pair deletions, said Frank D. Cohen, MPA, MBB, senior analyst with The Frank Cohen Group, LLC, in his analysis of the changes. Of the over 2,500 new pairings, 122 had a retroactive effective date of Jan. 1, 2012, while the remaining 2,399 went into effect on July 1. All of the code bundle deletions were effective June 30.

Distinguish Between Mutually Exclusive and Non-Mutually Exclusive Edits

As per the latest version of CCI edits, you cannot report duodenal intubations with upper GI endoscopy procedures when your gastroenterologist performs these services, as the code for duodenal intubations (43756, Duodenal intubation and aspiration, diagnostic, includes image guidance; single specimen [e.g., bile study for crystals or afferent loop culture]) is a column 2 code for the upper GI endoscopy codes. Note that some of the edits are mutually exclusive, while others are NME (non-mutually exclusive) edits.

What it means: When CCI marks a bundle as mutually exclusive with a modifier '0,' you cannot report the procedures mentioned in the column 2 separately, as it is bundled within the more comprehensive procedure listed in column 1. For NME edits with a modifier '1', you cannot typically report the procedures separately but under special circumstances, you can list the procedures using a suitable modifier such as 59 (Distinct procedural service).

Under CCI 18.2, mutually exclusive upper GI endoscopy codes with 43756 include the following:

• 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure])
• 43236 (...with directed submucosal injection[s], any substance)
• 43239 (...with biopsy, single or multiple)
• 43241 (...with transendoscopic intraluminal tube or catheter placement)
• 43242 (...with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy[s] [includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum and/or jejunum as appropriate])
• 43244 (...with band ligation of esophageal and/or gastric varices)
• 43247 (...with removal of foreign body)
• 43248 (...with insertion of guide wire followed by dilation of esophagus over guide wire)
• 43249 (...with balloon dilation of esophagus [less than 30 mm diameter])
• 43251 (...with removal of tumor[s], polyp[s], or other lesion[s] by snare technique)
• 43256 (...with transendoscopic stent placement [includes predilation])
• 43258 (...with ablation of tumor[s], polyp[s], or other lesion[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique)
• 43259 (...with endoscopic ultrasound examination, including the esophagus, stomach, and either the duodenum and/or jejunum as appropriate)

CCI 18.2 indicates that the upper GI codes that form column 1 codes with 43756 in column 2 (with the modifier 1) include the following:

• 43237 (...with endoscopic ultrasound examination limited to the esophagus)
• 43238 (...with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy[s], esophagus [includes endoscopic ultrasound examination limited to the esophagus])
• 43240 (...with transmural drainage of pseudocyst)
• 43243 (...with injection sclerosis of esophageal and/or gastric varices)
• 43245 (...with dilation of gastric outlet for obstruction [e.g., balloon, guide wire, bougie])
• 43246 (...with directed placement of percutaneous gastrostomy tube)
• 43250 (...with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery)
• 43255 (...with control of bleeding, any method)
• 43257 (...with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease)

Get a Handle on Other Intubation Bundles

When your gastroenterologist performs a duodenal intubation (43756 or 43757, Duodenal intubation and aspiration, diagnostic, includes image guidance; collection of multiple fractional specimens with pancreatic or gallbladder stimulation, single or double lumen tube, includes drug administration) and gastric intubation (43754, Gastric intubation and aspiration, diagnostic; single specimen [e.g., acid analysis] or 43755, ...collection of multiple fractional specimens with gastric stimulation, single or double lumen tube [gastric secretory study] [e.g., histamine, insulin, pentagastrin, calcium, secretin], includes drug administration) in the same session, you can only report the duodenal intubation, as indicated in CCI 18.2.

Observe Chemodenervation and Neurolytic Bundles

When your gastroenterologist performs a chemodenervation of the internal anal sphincter (46505, Chemodenervation of internal anal sphincter) and uses a neurolytic agent for destruction, you cannot report the two procedures together, as CCI 18. 2 indicates.

V18.2 of the edits specifies the following codes that form column 2 codes for 46505 with the modifier '1':

• 64630 (Destruction by neurolytic agent; pudendal nerve)
• 64640 (Destruction by neurolytic agent; other peripheral nerve or branch)

Learn more: For the complete set of the CCI 18.2, visit www.cms.gov/NationalCorrectCodInitEd -- or search for bundles affecting individual codes by using the CCI edits checker at https://www.aapc.com/codes/.