Gastroenterology Coding Alert

Hint: Observe modifier indicator to see if you can unbundle the codes.

While CPT^® 2014 brought in a slew of new codes for rigid and flexible endoscopy, Correct Coding Initiative (CCI) edits 20.0 added more guidelines to these codes. Find out what procedures you can or cannot report together.

Heed These Rigid Esophagoscopy Bundles With ERCP Codes

In case you are planning to report the new rigid endoscopy codes or the flexible transnasal endoscopy codes with any other endoscopy 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 bundles many of the rigid endoscopy codes and the flexible transnasalesophagoscopy codes with ERCP codes (43260, Endoscopic retrograde cholangiopancreatography [ERCP];… -43278) and small intestine endoscopy codes (44360, Small intestinal endoscopy, enteroscopy beyond second portion of duodenum…, -44379).

“Rigid esophagoscopy is rarely performed by gastroenterologists being more typically a procedure done by thoracic or ENT surgeons and is rarely done with other flexible endoscopy codes,” says Michael Weinstein, MD, Gastroenterologist at Capital Digestive Care in Washington, D.C., and former representative of the AMA’s CPT^® Advisory Panel.  But if you are planning on reporting any of these two procedural codes together, you first need to see if there are any edits that will prevent you from reporting both the CPT^® codes together. If there are edits, check the CCI modifier indictor to see if you can overcome the edits by appending a modifier to any one of the two 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 have a modifier indicator of ‘0.’However, other 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 are planning to report ERCP with stent removal (43275, Endoscopic retrograde cholangiopancreatography [ERCP]; with removal of foreign body[s] or stent[s] from biliary/pancreatic duct[s]) with a rigid esophagoscopy code (43191-43196) although it is quite unlikely that you will face up with such a scenario as your clinician will not generally perform these procedures together usually. While 43275 and 43191 (Esophagoscopy, rigid, transoral; diagnostic, including collection of specimen[s] by brushing or washing when performed [separate procedure]) are bundled with the modifier indicator ‘0,’ 43275 and 43194 (Esophagoscopy, rigid, transoral; with removal of foreign body) carry modifier indicator ‘1.’

So, even though these two set of codes are bundled by CCI, you can separately report 43194 with 43275 if your clinician removed a foreign body from the esophagus using a rigid scope inserted through the oral route and in the same session removed a stent or a foreign body from the biliary or pancreatic ducts when performing an ERCP. However, you will have to append modifier 59 (Distinct procedural service) to 43194 to let the payer know that two procedures were distinct and different and provide supporting documentation.

But, since the code bundling with 43191 carries the modifier indicator ‘0’ you cannot report 43275 and 43191 when both these services were performed at the same session. In such a case, you will only report 43275.

Tread Carefully When Reporting New Esophagoscopy Codes With EGD Codes

You will also face edits when reporting the new codes for flexible esophagoscopy through the oral route and upper EGD codes.

So, if you are planning on reporting any of the new flexible esophagoscopy codes with upper EGD codes or with other esophagoscopy codes, don’t forget to check for CCI edits to see if the codes are bundled. Also, if the codes are bundled check the modifier indicator to see if the codes can be unbundled.

Example: Suppose your clinician inserts a flexible scope orally to perform an esophagoscopy during which he removes a lesion from one area of the esophagus using a hot biopsy forceps. Then during the same session, he locates another lesion that he removes by ablation. You should report 43216 for removal of the lesion using hot biopsy forceps and report 43229 for the ablation of the other lesion.

If you look through CCI edits, you’ll see that 43216 is a column two code for 43229 with the modifier indicator ‘1.’ Since the codes can be unbundled, you report the two codes and append modifier 59 to 43216 to bypass the edits. Make sure you have supporting documentation.

Caveat: Most of the flexible esophagoscopy codes that are bundled with upper EGD codes carry the modifier indicator ‘0,’ which means that you cannot unbundle the codes and report them separately by appending a modifier. So, in most circumstances, you will not be able to report these new flexible esophagoscopy codes with other upper EGD codes.“This edit is typical of other bundled pairs where one procedure is a component of the other procedure” adds Weinstein. 

Check Bundling of New Codes With Intubation Codes

Most of the new esophagoscopy codes, new upper EGD codes and the new ERCP codes are bundled by CCI 20.0 with codes that you will use for intubation. “These same edits exist for the more established endoscopy codes that are familiar to your physicians,” reminds Weinstein.  So, according to CCI 20.0, you will have to watch out for code bundling if you are planning to report any of the newly introduced endoscopy codes with the following codes that you will use for intubation, such as:

• 43752 --- Naso- or oro-gastric tube placement, requiring physician’s skill and fluoroscopic guidance [includes fluoroscopy, image documentation and report]
• 43753 --- Gastric intubation and aspiration[s] therapeutic, necessitating physician’s skill [e.g., for gastrointestinal hemorrhage], including lavage if performed
• 43754 --- Gastric intubation and aspiration, diagnostic; single specimen [e.g., acid analysis]
• 43756 --- Duodenal intubation and aspiration, diagnostic, includes image guidance; single specimen (e.g., bile study for crystals or afferent loop culture]

Reminder: While most of these above mentioned edits carry the modifier indicator ‘1’ that allows you to unbundle the code edits, some of them are bundled with the indictor ‘0’ that disallows you to report such codes together. So, while looking out for edits, do observe the modifier indicator to know if you can unbundle the codes.