Gastroenterology Coding Alert

Revisions to the control-of-bleeding and dilation codes are among the significant changes of interest to gastroenterologists in CPT 2002. While most of the gastroenterology changes are fairly minor, they are part of a move toward compliance with the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and a gradual transition to CPT-5, the next generation of current procedural terminology.
 
"There aren't as many code changes for gastroenterology as there were last year, and many of the changes in the digestive section of CPT 2002 are surgical codes," says Joel Brill, MD, a gastroenterologist in Phoenix and the American Gastroenterology Association's representative for the CPT editorial advisory committee. "Many of the endoscopy revisions are part of the transition from CPT-4 to -5 and to HIPPA, where more granularity and more preciseness in coding descriptions are called for."

One of the main revisions to the endoscopy codes was the wording of the control-of-bleeding descriptions. The following control-of-bleeding codes have been revised: Note: Changes are in bold.
 

43227 esophagoscopy, rigid or flexible; with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
 

44366 small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
 

44378 small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
 

44391 colonoscopy through stoma; with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
 

45334 sigmoidoscopy, flexible; with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
 

45382 colonoscopy, flexible, proximal to splenic flexure; with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe,  stapler, plasma coagulator)
 

46614 anoscopy; with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator).
 
The phrase "any method" has been deleted from all of these definitions and has been replaced with a list of specific control-of-bleeding methods. This is mainly a stylistic change, and the codes still refer to all methods, Brill says. While the description list contains all the methods now used to control bleeding, any new methods would be covered by these codes as well.
 
Note: The only control-of-bleeding code that was not revised was 43255 (upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with control of bleeding, any method). This is a technical error, Brill says, which shouldn't make any difference to payers or providers.
 
Though injections are now specifically mentioned in the revised definition, sclerotherapy injections to control bleeding should still be reported with the more specific code 43243 (EGD with injection sclerosis of esophageal and/or gastric varices).
 
Also, the control-of-bleeding codes should not be used to report injections that do not control bleeding. "New CPT codes will be coming in the future for other injections in the digestive tract, such as botox injections for achalsia and India ink tattooing in the colon," Brill says.
 
Specific methods were added to the descriptions of two esophageal dilation codes:
 

43245 upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with dilation of gastric outlet for obstruction (e.g., balloon, guide wire, bougie)
 

46604 anoscopy; with dilation (e.g., balloon, guide wire, bougie).
 
This revision was made with the same rationale as the control-of-bleeding codes. Many gastroenterologists were confused as to when to use 43245 versus 43248 (EGD with insertion of guide wire followed by dilation of esophagus over guide wire), for example, and the members of the CPT editorial panel felt that further clarification was needed here, Brill explains.
 
Minor revisions were made to two ERCP codes:
 

43264 endoscopic retrograde cholangiopancreatography (ERCP); with endoscopic retrograde removal of calculus/calculi from biliary and/or pancreatic ducts
 

43265 endoscopic retrograde cholangiopancreatography (ERCP); with endoscopic retrograde destruction, lithotripsy of calculus/calculi, any method.

The phrase "stone(s)" has been replaced with  "calculus/calculi," which is the same as a stone, Brill says. He adds that this is another cosmetic change that CPT made to comply with the HIPAA mandate.

Additions and revisions were made to non-endoscopic codes that may be used in gastroenterology. New code 91123 (pulsed irrigation of fecal impaction) may be used occasionally by gastroenterologists. The code describes the specific method of using pulsed irrigation of fluids to remove a fecal impaction. This procedure is used frequently with spinal-cord injury patients and is performed in a hospital or long-term-care facility and should not be confused with the procedure for manual disimpaction.
 
A minor revision was made to 83013 (helicobacter pylori; analysis for urease activity, non-radioactive isotope). This code describes the analysis of the C-13 test for H. pylori. CPT removed the phrase "mass spectrometry" from the description to reflect the use of a new C-13 test that does not use that technology.
 
The code for fecal occult blood tests (82270, blood, occult, by peroxidase activity [e.g., guaiac], qualitative; feces, 1-3 simultaneous determinations) was changed also to reflect the fact that most patients will submit three specimens on a card, but that the gastroenterologist can bill only for a single test.

A new code in the special services, procedures and reports subsection of CPT 2002 may be of use to gastroenterologists in the future. Code 99091 (collection and interpretation of physiologic data [e.g., ECG, blood pressure, glucose monitoring] digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, requiring a minimum of 30 minutes of time) can be used to report the interpretation of physiological data transmitted digitally to a gastroenterologist's office.
 
A key to using this code appropriately is the word  "physiologic." This code does not refer to the endoscopic data that is transmitted with the new M2A disposable imaging capsule developed by Given Imaging that sends video images of the small bowel to a gastroenterologist for interpretation, Brill says. (The M2A capsule procedure should be billed with the "unlisted-procedure code" until an emerging-technology code is issued.)
 
Another key is the phrase "digitally stored and/or transmitted." Generally, the data will be transmitted through a monitor worn by the patient, either on a belt or the abdomen. It would not include, for example, the monitoring of a patient who is receiving total parenteral nutrition infusions at home that service would be more appropriately reported with a care-plan oversight code (99374-99380).
 
Brill thinks that gastroenterologists may use 99091 if tests like esophageal manometry are monitored digitally in the future. "I see a chip for manometry testing being implanted in the patient's esophagus," he explains. "If that chip transmits to a monitor worn by the patient, and the data is downloaded to the gastroenterologist's office, then it is possible that this code would be used."

Endoluminal gastroplication, a new technique used on patients with gastroesophageal reflux disease, has been assigned emerging-technologies code 0008T (upper GI endoscopy with suturing of the esophagogastric junction). The alphanumeric emerging-technologies codes are new to CPT 2002 and are assigned to new medical technologies that are going through the FDA approval process.
 
This category allows for the accumulation of research and data on the use and frequency of these codes, according to Glenn Littenberg, MD, FACP, a gastroenterologist in Pasadena, Calif., and a member of the AMA CPT editorial panel. While many of these new technologies may eventually be assigned the standard CPT five-digit numeric code, Littenberg stresses that reimbursement for these procedures is now each Medicare carrier and private insurance payer's prerogative.
 
Several new home-healthcare codes may be of interest to gastroenterology practices:
 

99505 home visit for stoma care and maintenance including colostomy and cystostomy
 

99560 home infusion of enteral nutrition, per diem
 

99562 ... total parenteral nutrition, per diem.

Gastroenterologists should not use these codes, Littenberg stresses. However, they may be used by nurses, physician assistants and other nonphysician practitioners who are affiliated with a gastroenterology practice.
 
"If a practice has a nonphysician provider working for them, it may report his or her services with these codes or use them internally to track productivity," Littenberg explains. "But a gastroenterologist performing these home-health services would still report them as an E/M service."
 
CPT 2002 codes go into effect on Jan. 1, 2002. However, providers have three months, until March 31, 2002, to use either CPT 2001 or 2002 codes. Gastroenterologists should ask their payers when they plan to adopt the CPT coding changes and update their systems.