Gastroenterology Coding Alert

Mind your gastric intubation coding, too, for conditional pairings.

Watch out when coding two new codes for manometric study with other procedures: 91117, and 91013.

Correct Coding Initiative (CCI) Edits 17.0 -- which took effect Jan. 1 -- does not allow simultaneous reporting of 91117 (Colon motility [manometric] study, minimum 6 hours continuous recording [including provocation tests, e.g., meal, intracolonic balloon distension, pharmacologic agents, if performed], with interpretation and report) and 88 other procedures; 91013 (Esophageal motility [manometric study of the esophagus and/or gastroesophageal junction] study with interpretation and report; with stimulation or perfusion during 2- dimensional data study [e.g., stimulant, acid or alkali perfusion] [List separately in addition to code for primary procedure]) and two other procedures. These edits mean you won't get paid for both, so get the lowdown on how to adhere or risk giving away your profits.

For the 17.0 version, "19,822 new edit pairs have been added to the database while 9,778 have been terminated, for a net gain of 10,044 new edit pairs," according to Frank Cohen, MPA, MBB, of the Frank Cohen Group, in his Dec. 14, 2010, "NCCI Version 17.0 Change Analysis" announcement.

New Codes Step Into The Spotlight of NME Pairings

Non-mutually exclusive (NME) codes are services that physicians often perform during the same session that are not billable together, with one as the comprehensive or larger procedure and the other as the component. The component code is included in the services represented by the comprehensive code.

Rule of thumb: You can bill individual components if the physician does not perform the entire comprehensive procedure. But if the physician performs the entire comprehensive procedure, you should bill the comprehensive code instead of the individual parts or components.

CCI 17.0 includes non-mutually exclusive edits for virtually every colon motility study (91117) code when performed with several CPT codes. Coding for 91117 overrides thefollowing codes when a physician performs both procedures in the same session:

Venous injection--

• 36000 -- Introduction of needle or intracatheter, vein
• 36400 -- Venipuncture, younger than age 3 years, necessitating physician's skill, not to be used for routine venipuncture; femoral or jugular vein
• 36405 -- ...scalp vein
• 36406 -- ...other vein
• 36410 -- Venipuncture, age 3 years or older, necessitating physician's skill (separate procedure), for diagnostic or therapeutic purposes (not to be used for routine venipuncture)
• 36420 -- Venipuncture, cutdown; younger than age 1 year
• 36425 -- ...age 1 or over
• 36430 -- Transfusion, blood or blood components
• 36440 -- Push transfusion, blood, 2 years or younger

Arterial catheter insertion--

• 36600 -- Arterial puncture, withdrawal of blood for diagnosis
• 36640 -- Arterial catheterization for prolonged infusion therapy (chemotherapy), cutdown

Other procedures--

• 37202 -- Transcatheter therapy, infusion other than for thrombolysis, any type (e.g., spasmolytic, vasoconstrictive)
• 43752 -- Naso- or oro-gastric tube placement, requiring physician's skill and fluoroscopic guidance (includes fluoroscopy, image documentation and report)
• Bladder introduction surgery codes 51701-51703
• Spine and spinal cord injection codes 62310-62319
• Extracranial nerves, peripheral nerves, and autonomic nervous system anesthesia codes 64400-64483 (except 64480), 64490, 64493, 64505-64530
• 69990 -- Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure)
• Gastroenterology codes 91120 (Rectal sensation, tone, and compliance test [i.e., response to graded balloon distention]) and 91122 (Anorectal manometry).

The same edits apply to 91117 during several specialty procedures:

• Cardiography and echocardiography codes 93000-93010, 93040-93042, 93318
• Pulmonary codes 94002, 94200, 94350, 94680-94681, 94690, 94770
• Routine Electroencephalography (EEG) codes 95812-95813, 95816-95829
• Special EEG test codes 95955
• Hydration and injection codes 96360, 96365, 96372, 96374-96376
• Moderation sedation codes 99148-99150.

Another new manometric study code 91013 lists as a comprehensive code for debuting category III code 0241T (Esophageal motility [manometric study of the esophagus and/or gastroesophageal junction] study with interpretation and report; with stimulation or perfusion during 3-dimensional high resolution esophageal pressure topography study [e.g., stimulant, acid or alkali perfusion] [List separately in addition to code for primary procedure]).

In reverse, 91013 acts as a component of 0240T (Esophageal motility [manometric study of the esophagus and/or gastroesophageal junction] study with interpretation and report; with 3-dimensional high resolution esophageal pressure topography), while 91117 lists as a component of 0242T (Gastrointestinal tract transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report) for NME pairings.

Logic: Physicians use two distinct types of commercial devices for esophageal motility studies, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel. It would not be appropriate to use both types at the same testing session and therefore the code pairings of 91010 and 91013 should be mutually exclusive from the new technology code pair of 0240T and 0241T. This year the listing of these codes in the CCI Edits for non-mutually exclusive code pairs is based on instructions from CMS and CPT.

"If 0240T and 0241T become permanent codes in the future then I would expect them to appear in the Mutually Exclusive CCI listing," he comments.

Hint: Some edit pair carries a modifier indicator of "1," meaning you can sometimes bypass the edit by filing your claim with an appropriate modifier. Don't forget to beef up with supporting documents your claim for both codes beforefiling with a modifier 59 (Distinct procedural service).

Gastric Intubation Codes Appear With Their Own Edits

New CPT codes 43753--43757 describe more specific scenarios adding granularity for when tubes are needed to treat or investigate patient symptoms compare to prior limited code option:

• 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)
• 43755 -- Gastric intubation and aspiration, diagnostic; collection of multiple fractional specimens with gastric stimulation, single or double lumen tube (gastric secretory study) (e.g., histamine, insulin, entagastrin, calcium, secretin), includes drug administration
• 43756 -- Duodenal intubation and aspiration, diagnostic, includes image guidance; single specimen (e.g., bile study for crystals or afferent loop culture)
• 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.

CCI Edits 17.0 defines specific component codes for each of these new codes, some of which include:

• 43753--
• 0213T -- Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level
• 36000
• 36600
• 51701 -- Insertion of non-indwelling bladder catheter (e.g., straight catheterization for residual vein)
• 62310 -- Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; cervical or thoracic
• 64445 -- Injection, anesthetic agent; sciatic nerve, single
• 94770 -- Carbon dioxide, expired gas determination by infrared analyzer
• J0670 -- Injection, mepivacaine hydrochloride, per 10 ml

43754--

• 0216T -- Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophysial) joint (or nerve innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)
• 36420
• 51703 -- Insertion of temporary indwelling bladder catheter; complicated (e.g., altered anatomy, fractured catheter/balloon)
• 93000 -- Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report

43755--

• 36425
• 64410 -- Injection, anesthetic agent; phrenic nerve
• 64505 -- Injection, anesthetic agent; sphenopalatine ganglion

43756--

• 37202 -- Transcatheter therapy, infusion for thrombolysis other than coronary
• 43752
• 94002 -- Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day

43757--

• 64420 -- Injection, anesthetic agent; intercostals nerve, single
• 74340 -- Introduction of long gastrointestinal tube (e.g., Miller-Abbott), including multiple fluoroscopies and films, radiological supervision and interpretation
• 94250 -- Expired gas collection, quantitative, single procedure (separate procedure).

43753, 43755 Override Tube Placement Procedure

Make sure you don't leave out mutually exclusive pairings for new gastric intubation codes 43753 and 43755. CCI Edits define mutually exclusive codes as services that could not reasonably be performed at the same session by the same provider on the same beneficiary.

CCI Edits 17.0 places 43753 in column 1 and 43752 in column 2. This edit has a modifier indicator of "1", so you may override it with a modifier when clinically appropriate. In the same manner, CCI Edits 17.0 pairs up 43755 with 43752 for a mutually exclusive matching with the same modifier indicator of "1".