Gastroenterology Coding Alert

More gastroenterologists are finding that commercial payers will reimburse for India ink tattooing of lesions removed during endoscopies, especially if they take the time to document and support their insurance claims.
 
India ink tattooing consists of using a needle to inject India ink into a lesion and marking it permanently so a gastroenterologist or surgeon can easily identify the lesion later. "I use it to see if a polyp has been removed completely," says Bergein F. Overholt, MD, FACP, MACG, a gastroenterologist in Knoxville, Tenn., and past president of the American Society for Gastrointestinal Endoscopy. "Often when taking off a sessile polyp, it's difficult to see if you got it completely. So you use India ink tattooing to mark the site of the polyp, then go back and biopsy the site later."

Despite its value to the patient and the gastroenterologist or surgeon, India ink tattooing does not appear to be a service that Medicare payers will reimburse. There is no specific CPT code for the procedure, and according to the Correct Coding Initiative (CCI), the "identification of anatomical landmarks" is one of many generic services for which it would be "inappropriate to separately code based on standard medical and surgical principles."
 
Many commercial insurers, however, will provide extra reimbursement if the procedure is properly documented. After reading an article about India ink tattooing in the January 2000 Gastroenterology Coding Alert, Sandi Scott, CPC, CORT, director of coding at the Mission Internal Medicine Group, a practice in Mission Viejo, Calif., that has four gastroenterologists, started billing the procedure separately and has had nearly 100 percent success in getting payment. "The gastroenterologist should get paid for doing the extra work because if the patient has to go back for surgery, he or she has done the surgeon a favor by making it easier to find the spot of the lesion," she explains.

To bill the procedure, Scott reports the appropriate endoscopy code first, followed by the unlisted-procedure code for the site of the body being tattooed. To code for the marking of lesions during a colonoscopy when a polyp is removed by the snare technique, she would list 45385 first and then 44799 (unlisted procedure, intestine).
 
Because an unlisted-procedure code is being reported, the gastroenterologist must also submit additional documentation to the payer along with the claim. "We send the whole operative report along with the claim," Scott says. "It explains the tattooing procedure, the additional amount of time that it took, what was done, and the type of ink that was used."
 
Scott's practice is usually reimbursed about 50 percent of the amount billed. Scott feels this reduced fee is in line with the standard payment rule for multiple surgeries, which states that for two or more procedures with different endoscopic base codes performed on the same day, the procedure with the highest relative value unit will be reimbursed at full value. The lesser-valued procedures will be reimbursed at 50 percent of the usual fee.
 
Although all of Scott's claims were to private payers, she wouldn't hesitate to bill Medicare for the procedure. "All of the payers that we have submitted this to have been commercial insurers, but I would try it with a Medicare patient," she says.
 
However, if a payer, whether Medicare or a private insurer, has indicated in writing its reasons for not reimbursing India ink tattooing, then gastroenterologists should stop coding for the procedure with that particular payer. Continuing to bill for a service that has been specifically denied could flag a practice for an audit.

For gastroenterologists whose payers deny the India ink tattooing claim, a letter of appeal may be needed to secure payment. For a while, Overholt was systematically appealing any denial by private insurers of India ink tattooing claims. In a separate letter, he would present cost estimates of the tattooing procedure, which included materials and supplies used as well as the additional nursing time required. He would recommend a reimbursement of $100 and end the letter by stating that he was willing to discuss this matter further with the payer.
 
"India ink tattooing is a very valuable technique that takes time, carries some risk of infection and has a cost to it," he says in explaining why he decided to pursue these appeals. "It should be reimbursed."
 
While appealing a denial takes time, Overholt feels it helps win reimbursement from some private payers. And once these payers agreed to an initial reimbursement, Overholt believes they tended automatically to honor other lesion-marking claims in subsequent billings.