Gastroenterology Coding Alert

" The digestive section of the CPT 2001 manual contains several new cross-references that explain which radiological code should be reported when fluoroscopic guidance is provided during a gastrointestinal procedure. While this is some help to gastro coders, many procedures that frequently use fluoroscopic guidance still do not contain a cross-reference, making it unclear which radiological code to report.

Fluoroscopy is a continuous x-ray technique that gastroenterologists may use with or without contrast material to provide visual guidance, according to Bergein F. Overholt, MD, FACP, MACG, a gastroenterologist in Knoxville, Tenn., and past president of the American Society for Gastrointestinal Endoscopy. While the most common use of fluoroscopy is during ERCP (43260), it may also be incorporated into other procedures such as esophageal dilations or percutaneous gastrostomy (PEG) tube placements.

When a gastrointestinal procedure and an imaging, such as fluoroscopy, are performed together, the imaging portion is designated as radiological supervision and interpretation. In this instance, two separate CPT codes should be reported to describe the combination of services provided.

Fluoroscopy Not Mentioned in Code Descriptor

Matching the correct radiological supervision and interpretation (S&I) code with a GI procedure code is made more complicated, because very few of the radiological code descriptors include the word fluoroscopy. For example, 74360 (intraluminal dilation of strictures and/or obstructions [e.g., esophagus] radiological supervision and interpretation), which should be reported when fluoroscopic guidance is used in combination with an esophageal dilation, never mentions the word fluoroscopy.

Thats because fluoroscopy is not the only method of imaging guidance that can be used during a dilation of strictures, says Cindy Parman, CPC, CPC-H, co-owner of Coding Strategies, Inc., an Atlanta-based firm that supports 1,000 radiologists and 350 physicians from other specialty areas. The 70000-series codes in CPT are really designed for radiologists, so physicians of any other specialty are going to have difficulty understanding how to use them.

Use 76000 as Last Resort

Many gastroenterologists make the mistake of reporting 76000 (fluoroscopy [separate procedure], up to one hour physician time, other than 71023 or 70134 [e.g., cardiac fluoroscopy]) when they use fluoroscopy, which could cost them reimbursement dollars. For example, the 2001 transitioned facility relative value units (RVUs) for 76000-26 (professional component) is only .24, versus a comparable RVU of .77 for 74360-26. (Whether to use modifier -26 is explained later in this article.)

Although its descriptor includes the word fluoroscopy, 76000 should only be used when a more specific code is not available, Parman says. What you dont want to do is use a code that looks close to what you did because it uses the word fluoroscopy and you think nothing else will work.

Billing for Fluoroscopy During ERCP

Fluoroscopy is used the most during ERCPs. However, a radiologist will most likely bill for the fluoroscopic imaging during an ERCP and not a gastroenterologist. The majority of the time, there will be a radiologist present and he or she will be billing for the S&I, says Peter Pardoll, MD, a gastroenterologist in St. Petersburg, Fla., and the former co-chair of the National Gastrointestinal Carriers Advisory Committee.

Sometimes I cant get a radiologist to come down to the procedure room, so then I handle the radiological S&I with the assistance of a radiology technician, and I bill for the fluoroscopy. If you do the work, you should be the one to get paid for it.

In the rare case where a gastroenterologist performs the fluoroscopic supervision and guidance during an ERCP, CPT 2001 tells coders to use one of the following three radiological codes depending on whether the biliary, pancreatic or both ductal systems were visualized:

74328 endoscopic catheterization of the biliary ductal system, radiological supervision and interpretation

74329 endoscopic catheterization of the pancreatic ductal system, radiological supervision and interpretation

74330 combined endoscopic catheterization of the biliary and pancreatic ductal systems, radiological supervision and interpretation

Use 74360 for All Dilations

Another common use of fluoroscopy in gastroenterology is with esophageal dilations, which are performed when there is a stricture or abnormal narrowing of the esophagus. Fluoroscopy helps determine where the dilator is going, Overholt explains. It can also help direct the guidewire.

If fluoroscopy is used with either an esophagoscopy with balloon dilation (43220) or esophagoscopy with dilation over a guide wire (43226), CPT 2001 states that 74360 should be used to report the fluoroscopy. There is no CPT cross reference, however, for the related esophagogastroduodenoscopy (EGD) procedures EGD with balloon dilation (43249) and EGD with dilation over a guide wire (43248). Nevertheless, the same code, 74360, should be billed if fluoroscopy is performed with either of these procedures.

Code 74360 should also be used whenever fluoroscopy is used with an esophageal dilation, says Overholt. Other dilation codes that might be reported in combination with fluoroscopy code 74360 include the non-endoscopic manipulation codes 43450 (dilation of the esophagus, by unguided sound or bougie, single or multiple passes) and 43458 (dilation of the esophagus with balloon [30 mm diameter or larger] for achalasia).

When the removal of a foreign body in the esophagus (43215 and 43247) is performed under fluoroscopic guidance, CPT 2001 states that 74235 (removal of foreign body[s], esophageal, with use of balloon catheter, radiological supervision and interpretation) should be used to report the radiological component.

Use 74350 for All PEG Tube Placements

Fluoroscopy can also be used to guide the placement and positioning of various tubes. When the placement of a PEG tube (43246 or 43750) is performed under fluoroscopic guidance, 74350 (percutaneous placement of gastrostomy tube, radiological supervision and interpretation) should be used to report the radiological component. The same code should also be reported when fluoroscopy is used with the placement of a percutaneous jejunostomy tube in the small intestine (44372), or the conversion of a PEG tube to a percutaneous jejunostomy tube in the small intestine (44373), according to Linda Parks, MA, CPC, lead coder at Atlanta Gastroenterology Associates, a 23-physician practice.

When there is a change of gastrostomy tube (43760) performed under fluoroscopic guidance, the radiological S&I should be reported with 75984 (change of percutaneous tube or drainage catheter with contrast monitoring [e.g., gastrointestinal system, genitourinary system, abscess], radiological supervision and interpretation).

Use 76000 for Some Tube Placements

The insertion of naso-gastric (NG) tubes may also require fluoroscopic guidance. When that occurs, there is a new CPT code, 43752, which is used to report the NG tube guidance necessitating a physicians skill. Code 76000 is the appropriate radiological code to use with an NG tube insertion, according to CPT. Parker notes, however, that her practice has yet to be reimbursed for this procedure by either commercial insurers or Medicare, which has not assigned an RVU to 43752. Therefore, it is unlikely that a gastroenterologist will be reimbursed for the use of fluoroscopy in this situation.

Ph probes, which are inserted into the patients esophagus for purposes of monitoring esophageal reflux (91032 and 91033), may also require the skill of a gastroenterologist and the use of fluoroscopy in some difficult cases. While CPT 2001 does not contain a radiological cross reference for 91032 or 91033, 76000 could be used, recommends Parman, who adds that this one example is when the general fluoroscopy code is appropriate to use.

The general rule is that this procedure is not normally done under fluoroscopy, and the gastroenterologist may or may not get paid for it, she explains. But when a more specific code is not available, gastroenterologists should use code 76000 or 76001 (fluoroscopy, physician time more than one hour, assisting a non-radiologic physician [e.g., nephrostolithotomy, ERCP, bronchoscopy, transbronchial biopsy]).

Attach Modifier -26 to Radiological Code

Finally, many gastroenterologists question whether modifier -26 needs to be added to the radiological code. Certain medical procedures are made up of a physician (professional) component and a technical component, which represents the value assigned to the ownership and maintenance of the equipment. (Though CPT guidelines do not specifically address billing for the technical component of a procedure, Medicare and some commercial insurers have designated the modifier -TC to represent this.)

When a procedure has both professional and technical components, a gastroenterologist must own (or partially own by being a partner in a medical practice) the equipment being used to bill the global procedure code. If the physician does not own the equipment being used, modifier -26 should be added to the procedure code.

Some gastroenterologists argue that the use of the phrase radiological supervision and interpretation in all the fluoroscopy codes indicates that these codes are not made up of two components, but only the one professional component. Therefore, modifier -26 should not be added to any fluoroscopy code, and the physician should receive the higher reimbursement of the global code.

While there are codes that do represent only the professional component of a procedure, such as ECG code 93010 (electrocardiogram, routine ECG with at least 12 leads; interpretation and report only), the radiological S&I codes all contain both a technical and professional component code, according to Parman. By looking at the [Medicare] fee schedule for physicians, you can see that all these codes are listed with their global values and then are broken down into their professional and technical components, she explains.

Most gastroenterologists dont own fluoroscopic equipment because it is so expensive, and those procedures requiring it are performed at a hospital, according to Overholt. In most situations, therefore, modifier -26 should be attached to all fluoroscopic codes."