Gastroenterology Coding Alert

Recovery audit contractors could soon be on the hunt for unbundling issues.

Your coding practices, telehealth policies, and even patient flow have been impacted by the onset of the COVID-19 public health emergency (PHE), but you may not be aware of the fact that recovery audit contractor (RAC) audits have also ceased for the time being. The temporary auditing reprieve prompted by the PHE has given gastroenterology practices time to shore up any issues that may have been on their pre-pandemic radar screens, one of which involves ultrasound coding.

Background: On March 4, 2020, several Part B RACs announced they would be reviewing claims that include unbundling for “Procedures that including imaging.” Specifically, “the focus of this issue is to target claims where the definition of the procedure code includes imaging and imaging was then unbundled,” Part B RAC Cotiviti notes on its Approved Issues list.

Knowing that this issue will be on RACs’ radar screens when audits resume, should allow GI practices time to absorb what this situation involves and provide practices with an opportunity to correct the issue. Consider these tips to shore up your imaging claims.

First Step: Check the Descriptor

Your first step in determining whether you can report imaging with a procedure is to check the code descriptor. In many cases, this will be the quickest way to know whether you can separately report imaging.

For instance, if you perform esophagogastroduodenoscopy (EGD) with ultrasound, you should report 43259 (Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination, including the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis) without an additional code for imaging. That’s because the descriptor clearly states, “with endoscopic ultrasound examination.”

This is the case with many GI-specific codes, but not all of them. For instance, if the physician incises the esophagus and removes a foreign body lodged there, you’ll report 43020 (Esophagotomy, cervical approach, with removal of foreign body). This descriptor makes no mention of guidance being included, so if the physician used guidance, you can separately report the most applicable guidance code, such as 76536 (Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real time with image documentation).

Second Step: Consult NCCI, Payer Guidelines

Even if a code descriptor doesn’t mention that guidance is included, there are occasions when the National Correct Coding Initiative (NCCI) precludes you from reporting a guidance code with a procedure code. Therefore, you should always consult the NCCI edits — as well as specific payer guidelines — to determine if a code pair is bundled before reporting the services together.

In the example above, there are no NCCI edits that prevent you from reporting 43020 and 76536 concurrently, although some payers may still require you to append a modifier such as 59 (Distinct procedural service) to the guidance code to ensure payment.

Third Step: Review Parenthetical Notes in CPT^®

In addition to reading the code descriptors, NCCI edits, and payer guidelines, you will also want to review all of the parenthetical notes in the CPT^® code book, because these can offer important information about when you can and can’t bill guidance codes along with procedure codes.

For example, a parenthetical note below code 76975 (Gastrointestinal endoscopic ultrasound, supervision and interpretation) states, “Do not report 76975 in conjunction with…” and then goes on to list over a dozen GI-specific codes, including 43238 (Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/ biopsy(s), (includes endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures)) and 45391 (Colonoscopy, flexible; with endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures).

Continue Coding Correctly

Although it’s unclear when the RAC audits may ramp back up again, one thing that is confirmed is that you should still code accurately and within the regulations during the PHE. CMS has not said whether it will review claims submitted during the PHE-period once it relaunches audits, but the agency did say, “CMS may conduct medical reviews during or after the PHE if there is an indication of potential fraud.”

Therefore, you must continue coding accurately, no matter how many auditors are reviewing claims at any given time.