Gastroenterology Coding Alert

Don’t forget to check CCI when reporting multiple endoscopy procedures together.

With newer codes come greater set of edits and rules. Just as you have begun getting used to the new endoscopic and ERCP code ranges, CCI 20.1 has brought in its own set of edits that apply to these codes. These edits let you know which of these codes you can or cannot report together.

“Overall, it’s a bit of a yawn this time, which is probably good. There are 4,322 new edit pairs, bringing the total active list to 1,314,537 active pairs,” says Frank Cohen, MPA, MBB, principal and senior analyst for The Frank Cohen Group in Clearwater, Fla. “Nearly 80% of the new edit pairs were defined by the policy statement “CPT® Manual or CMS manual coding instructions.”

Don’t Make the Mistake of Reporting Guide Wire Insertions Separately

Although you have separate codes for guide wire insertion (during an esophagoscopy or an EGD) over which your clinician will pass a dilator, you should not report the insertion of the guide wire separately. CCI 20.1 has made this clear by bundling these codes with the modifier indicator ‘0,’ which means you cannot break this edit using any modifier.

So, you cannot report 43226 (Esophagoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator[s] over guide wire) with these dilation CPT® codes:

• 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 (Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon [30 mm diameter or larger] [includes fluoroscopic guidance, when performed])

Reminder: Again, you are not allowed by CCI 20.1 to report the code for guide wire insertion during an EGD (43248, …with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire) with 43233.

Example:Your gastroenterologist reviewed a patient with symptoms of dysphagia and reflux. He introduces a flexible scope through the mouth and reaches the esophagus where he observes a stricture. He then introduces a guide wire and passes a dilator over it. Then he performs a dilation to overcome the stricture.

In this case, you are not allowed to report 43248 because the scope did not reach the stomach.   You should only report 43226 for the esophageal dilation.  “The  dilation code 43213 is only used by surgeons who access the esophagus from a surgical incision into the stomach cavity allowing them to pass a dilator into the esophagus from below in a “retrograde” direction,” reminds Michael Weinstein, MD, Gastroenterologist at Capital Digestive Care in Washington, D.C., and former representative of the AMA’s CPT® Advisory Panel. 

Observe Caution When Reporting Same Session ERCP Procedures

In case you are planning on reporting ERCP procedures like stent placements or removals together, you will have to check for bundling between these procedural codes. CCI 20.1 has introduced several edits to these procedures, so it is best to check if codes are bundled prior to reporting them for the same session on the same calendar date of service.

According to CCI 20.1, you’ll face edits if you are reporting stent placements (43274, Endoscopic retrograde cholangiopancreatography (ERCP); 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) with removal of foreign body or stent code (43275, …with removal of foreign body(s) or stent(s) from biliary/pancreatic duct[s]).

Similarly, you will face code bundling when reporting the CPT® code for exchange of a 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) with 43274 or with 43275.

Heads up: The modifier indicator to the above mentioned codes is ‘1,’ which means that you can undo the code bundling by using a suitable modifier on the column 2 code in the CCI edits. But, you unbundle the codes only when your clinician performs these  procedures in two different sites. You will need to provide suitable documentation supporting your claims to inform the payer these procedures were done in two sites.

Example: Your gastroenterologist performs ERCP and performs removal of a stent in the pancreatic duct and placement of a stent in the biliary duct. He does not place any stent in the pancreatic duct. According to CCI 20.1, you will hit an edit when trying to report 43275 for the removal of the stent in the pancreatic duct with 43274 for the placement of the stent in the biliary duct.

Since 43275 is the column 2 code in the CCI edit bundle between 43274 and 43275, you have to append the modifier 59 (Distinct procedural service) to 43275. Be sure to provide documentation to inform the payer that your clinician performed these two procedures in two different sites, namely, the pancreatic duct and the biliary duct. This will enable payment for both the procedures separately although multiple endoscopic reduction rules will apply.

Know What to Report For Transmural Injections to Celiac Plexus

Although you have distinct CPT® codes for injections of anesthetic agents (64530, Injection, anesthetic agent; celiac plexus, with or without radiologic monitoring) or destructive neurolytic agents (64680, Destruction by neurolytic agent, with or without radiologic monitoring; celiac plexus)into the celiac plexus, you are not allowed to report these codes when your clinician performs these procedures during an EGD. 

In such a case, you should report 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]) instead of 64530 or 64680. CCI 20.1 bundles 43253 with 64530/ 64680 with the modifier indicator ‘0,’ that lets you know that these codes cannot be reported together under any circumstances.