Gastroenterology Coding Alert

Look at CCI to see if the two ERCP procedures you are planning to report face bundling.

While CPT® 2014 broadened your endoscopic and ERCP code ranges, CCI 20.0 provides more clarity on which of these codes can be or cannot be reported together.

“As is customary for the first update of a given year, there are a lot of new edit pairs: 61,120 to be exact,” says Frank Cohen, MPA, MBB, principal and senior analyst for The Frank Cohen Group in Clearwater, Fla. “Factor in the number of terminations (13,107) and we see a net gain this coming quarter of 48,013 new edit pairs.”

Don’t Report New EGD Codes With Other EGD Codes Without Checking CCI

In case you are planning to report the new EGD codes with any other EGD or esophagoscopy procedures, you should check CCI edits to see if any of the codes are bundled and if so the modifier indicator to know if the code bundling can be overridden.

CCI 20.0 has introduced bundling between the newly introduced EGD codes, 43233 (Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon [30 mm diameter or larger] [includes fluoroscopic guidance, when performed]); 43253 (…with transendoscopic ultrasound-guided transmural injection of diagnostic or therapeutic substance[s] [e.g., anesthetic, neurolytic agent] or fiducial marker[s] [includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis]); 43254 (…with endoscopic mucosal resection); 43266 (…with placement of endoscopic stent [includes pre- and post-dilation and guide wire passage, when performed]) and 43270 (…with ablation of tumor[s], polyp[s], or other lesion[s] [includes pre- and post-dilation and guide wire passage, when performed]) and other EGD procedural codes and esophagoscopy codes.

Remember: The modifier indicator ‘0’ indicates you cannot override the edits with the use of a modifier. You’ll find a lot of these edits, especially the bundling with esophagoscopy procedures, have a modifier indicator of ‘0.’However, some code edits carry the modifier indictor ‘1,’ which means you can report the two codes together with a suitable modifier appended to the code in column two of the edits — but make sure you have supporting documentation.

Example: According to CCI 20.0, you’ll face edits if you report the new code for tumor removal by ablation (43270) with the code for removal of a lesion using a snare (43251). However, the modifier indicator for the code bundling is ‘1,’ which means you can override this edit by using a modifier, such as 59 (Distinct procedural service). Appending a modifier will enable you to report both the codes together. You will have to provide supporting documentation to inform the payer your clinician removed one lesion with a snare and obliterated another by ablating it.

However, if your clinician had to perform dilation using a bougie to overcome a stricture (43245) and in the same session he performed ablation to remove a lesion, you cannot report 43245 with 43270. CCI 20.0 bundles these two codes with the modifier indicator ‘0.’ So, if your gastroenterologist performs these two procedures, you’ll only report 43270 and not report both the codes. If you report both the codes, your claim for 43245 will be denied and only your claim for 43270 will be paid out.

Exercise Caution When Reporting Two ERCP Procedures Together

Even though descriptors to various ERCP codes have been modified to include certain procedures performed together, CCI 20.0 has bundled many codes in the ERCP CPT® code range 43260-43278 to further clarify which of the procedural codes cannot be reported together.

According to CCI 20.0, you are not allowed to report 43277 (I] or of ampulla [sphincteroplasty], including sphincterotomy, when performed, each duct) when your gastroenterologist performs these ERCP procedures in the same session:

• 43264 (…with removal of calculi/debris from biliary/pancreatic duct[s]);
  
• 43265 (…with destruction of calculi, any method (e.g., mechanical, electrohydraulic, lithotripsy);
  
• 43274 (…with placement of endoscopic stent into biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent);
  
• 43276 (with removal and exchange of stent[s], biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent exchanged);
  
• 43278 (…with ablation of tumor[s], polyp[s], or other lesion[s], including pre- and post-dilation and guide wire passage, when performed).
  

Coding tip: The modifier indictor to all the above mentioned ERCP code bundles is ‘1,’ which means you can use a modifier to unbundle the codes. But you can do this only if your clinician performs the procedures mentioned in the bundle in two different sites.

Example: You’ll hit an edit if you are planning to report 43264 with 43277. This edit cannot be overridden if your gastroenterologist is performing both the procedures in the same site, for example, in the pancreatic duct. But, if your clinician is performing the removal of the calculi from the biliary duct and performing balloon dilation in the pancreatic duct, you can override the edit by using the modifier 59. You need to append the modifier to the code in column 2 of the edits — which, in this case, is the CPT® code 43277. You will need to provide supporting documentation to inform the payer your clinician performed these procedures in two different sites or else the claim for 43277 will be denied.

Check for Edits When Reporting Photodynamic Therapy Add-on Code

You report the add-on code +96570 (Photodynamic therapy by endoscopic application of light to ablate abnormal tissue via activation of photosensitive drug[s]; first 30 minutes [List separately in addition to code for endoscopy or bronchoscopy procedures of lung and gastrointestinal tract]) when your gastroenterologist performs photodynamic therapy to ablate any tissue of the GI tract. You report this code as an add-on code to other endoscopy procedural codes.

However, CCI 20.0 has bundled many esophagoscopy and EGD procedural codes with +96570. When reporting this add-on code, you are not allowed to report these procedural codes as they are bundled by CCI:

• 43211 (Esophagoscopy, flexible, transoral; with endoscopic mucosal resection)
  
• 43212 (…with placement of endoscopic stent [includes pre- and post-dilation and guide wire passage, when performed])
  
• 43213 (…with dilation of esophagus, by balloon or dilator, retrograde [includes fluoroscopic guidance, when performed])
  
• 43214 (…with dilation of esophagus with balloon [30 mm diameter or larger] [includes fluoroscopic guidance, when performed])
  
• 43233
  
• 43253
  
• 43254
  
• 43266
  
• 43270
  

Reminder: The modifier indicator to the above mentioned code bundles is ‘1,’ which means you can override the edit by appending a modifier to the esophagoscopy or the EGD codes that are listed above.