Gastroenterology Coding Alert

Bonus: Find out which gastro code CPT 2007 crossed out

Although you only have one CPT 2007 addition and one deletion to learn by Jan. 1, you need to learn them soon. No grace period means that you have to update your coding practices now.

Good advice: -You and your providers must become familiar with new codes, regulations and so on as soon as the AMA releases them -- rather than waiting, as people used to do with the grace periods,- says Jo Ann Steigerwald, RHIT, ACS-GI, ACS-OH, president of Medical Business Specialists Healthcare Consulting in Baraboo, Wis. In other words, your responsibility is to -implement new policies as needed to make certain you-re cording correctly and compliantly, and of course, to your best advantage.-

Welcome New PillCam ESO Code

You have a new code to use to your advantage in 2007 -- 91111 (Gastrointestinal tract imaging, intraluminal [e.g., capsule endoscopy], esophagus with physician interpretation and report). -I am very excited about this code,- says Lori Veasey, office manager of Gastroenterology Group of South Jersey PC in Vineland, N.J.

Difference: This new code specifically represents visualizing the esophagus only, whereas 91110 (Gastrointestinal tract imaging, intraluminal [e.g., capsule endoscopy], esophagus through ileum, with physician interpretation and report) indicates visualizing the esophagus, stomach, duodenum, jejunum and ileum, Steigerwald says.

Rationale: -CPT created 91111 to report the PillCam ESO. The ESO is different from the PillCam SB (small bowel), as it is designed to specifically target and visualize the esophagus,- says Joel V. Brill, MD, the AMA CPT Advisory Committee member from the American Gastroenterological Association in Phoenix. The wireless capsule has cameras at both ends with a short battery life.

Providers can test for -reflux, varices, Barrett's esophagus, ulcers and so on,- Veasey says. -The patient is not required to take a full day off work because they will not undergo sedation and can be at our practice for the entire test, which only takes 20 minutes.-

Perfect Your Chance for Payment

In the past: If you wanted to perform a PillCam that visualized only the esophagus, you would have to report 91110 with modifier 52 (Reduced services). -But if you reported 91110-52, Medicare and other payers reduced the reimbursement by 50 percent, which would be inadequate to cover the cost of the capsule, much less cover the practice expense overhead and physician work associated with the procedure,- Brill says.

-We-ve been doing the PillCam ESO since its release in 2004 and have received denials. Some payers do reimburse, but they are few and far between. The ESO reimbursement hotline told us to bill with 91299 (Unlisted diagnostic gastroenterology procedure), while the product rep said 91110-52. Our confusion will come to a screeching halt when this new code goes into play,- Veasey says.

Caution: You may still have a struggle for reimbursement. Some payers consider PillCam ESO to be -experimental- or -investigational- and will not cover the procedure.

Tactic: -The argument is to look up the FDA approval dates that make the procedure no longer investigational and provide the date and approval number,- Steigerwald says.

Also, be sure you-ve got your modifiers in order. If the physician provides only the professional portion of the procedure (that is, interpretation and report of the results), you should append modifier 26 (Professional component) to 91111. If your physician provides both the professional and technical components of the procedure, you needn't attach any modifiers.

You should always make sure you maintain appropriate clinical records in case the payer should elect to audit claims, Brill says.

Say Goodbye to Gastric Saline Test

You should be aware of the one CPT 2007 deletion that may affect your practice. You-ll have to cross out 91060 (Gastric saline load test) as of Jan. 1. Nevertheless, this deletion shouldn't be traumatic.

-Coders seldom reported this service,- Steigerwald says. -In 2004 (the most recent data available), all specialties only reported this code just 28 times -- and of those, payers denied 16.-