Gastroenterology Coding Alert

Don't overlook two revised codes for esophageal pH monitoring.

If you've been looking for a code on colon motility study and being frustrated for the lack of it, your search is over. CPT 2011 debuts a new code for a manometric study, along with two revised codes for esophageal pH monitoring.

For gastroenterology, you have a lot of changes to sort through -- many involving deletions on low use codes or clean-up work.

Discover How to Use Two New Manometric Study Codes

You should pay attention on two new codes for a manometric study: 91117 (Colon motility [manometric] study, minimum 6 hours continuous recording [including provocation tests, e.g., meal, intracolonic balloon distension, pharmacologic agents, if performed], with interpretation and report), and 91013 (Esophageal motility [manometric study of the esophagus and/or gastroesophageal junction] study with interpretation and report; with stimulation or perfusion during 2-dimensional data study [e.g., stimulant, acid or alkali perfusion] [List separately in addition to code for primary procedure]).

Background: "There was a high request from pediatrics for a colon motility study code with a minimum of 6 hours of recoding," explained Joel V. Brill, MD, AGAF, CHCQM, American Gastroenterological Association, AMA/Specialty Society Relative Value Update Committee (RUC) Advisory Committee Member along with Glenn D. Littenberg, MD, FACP, American Society of Gastrointestinal Endoscopy, AMA CPT Advisory Committee Member in their presentation "Gastroenterology" at the CPT and RBRVS 2011 Annual Symposium.

Important: CPT 91117 is just for the study itself, not for the same session with catheter placement. The radiologist may place the catheter in a prior procedure and the gastroenterologist may come in and out to supervise the testing and any provocations that are performed. Thus, you should include the provocations in the study and report 97117 only once no matter how many times the testing is done.

You can use 91013 in cases like assessment of the effect on the measured esophageal motility when the patient's esophagus is exposed to different stimulant liquids, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel. The code also applies when intravenous medications are administered to try to produce symptoms. CPT 91010 is included in 91013 and would not be billed separately, he adds.

Revise The Way You Use 91034, 91035

Aside from debuting 91117 and 91013, CPT 2011 has revised esophageal pH monitoring codes to describe the site of attachment:

• 91034 -- Esophagus, gastroesophageal reflux test, with nasal catheter pH electrode[s] placement, recording, analysis and interpretation
• 91035 -- ...with mucosal attached telemetry pH electrode placement, recording, analysis and interpretation

The revisions state that 91034 is for the nasal approach where the catheter goes through the nose and down the patient's neck to the monitor. The patient walks around for 24 hours wearing the device and recording her symptoms of belching, pain, etc. "The device manufacturers found a way to directly attach the device into the nose without having to have a catheter through the nose," says Littenberg. He adds that this is the patient-preferred approach.

The speakers discussed these guidelines to answer some frequently asked questions:

• You can only bill the esophageal pH study once even if the physician does it for more than 48 hours.
• If the physician placed the catheter in an ASC, the center cannot be involved in the staffing, physician work, or equipment. The office has to provide all those items and bill for them.

•If the gastroenterologist does an office endoscopy for abnormalities and then places the capsule on same day, you may bill both the study 93015 and the scope (43235, Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) with modifier 59 (Distinct procedural service). "Often, you report 91035 on the day the telemetry recorder is taken off and that's not the same day as the scope and/or office visit," clarifies Littenberg.

Check Out These Other Gastro Code Revisions

Other revisions concerning the gastroenterology practice include:

• 91010 -- Esophageal motility (manometric study of the esophagus and/or gastroesophageal junction) study with interpretation and report; 2-dimensional data
• 0184T -- Excision of rectal tumor, transanal endoscopic microsurgical approach (i.e., TEMS), including muscularis propria (i.e., full thickness)
• New CPT codes 43753 - 43757 add granularity prior to gastric intubation code option:
• 43753 -- Gastric intubation and aspiration(s) therapeutic, necessitating physician's skill (e.g., for gastrointestinal hemorrhage), including lavage if performed
• 43754 -- Gastric intubation and aspiration, diagnostic; single specimen (e.g., acid analysis)
• 43755 -- Gastric intubation and aspiration, diagnostic; collection of multiple fractional specimens with gastric stimulation, single or double lumen tube (gastric secretory study) (e.g., histamine, insulin, pentagastrin, calcium, secretin), includes drug administration
• 43756 -- Duodenal intubation and aspiration, diagnostic, includes image guidance; single specimen (e.g., bile study for crystals or afferent loop culture)
• 43757 -- Duodenal intubation and aspiration, diagnostic, includes image guidance; collection of multiple fractional specimens with pancreatic or gallbladder stimulation, single or double lumen tube, includes drug administration

These new codes describe more specific scenarios for when tubes are needed to treat or investigate patient symptoms compare to prior limited code option.

E/M, Radiology Changes Offers a Sneak Peek

Check out more new codes and guidelines on radiology and E/M that can have an effect in your gastroenterology practice's success.

Scenario: "Middle days" observation care where a patient is admitted to observation and remains in that status for three or more days. CPT 2011 addresses this with three new codes:

• 99224 " Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: Problem focused interval history; Problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 15 minutes at the bedside and on the patient's hospital floor or unit.
• 99225 " ... an expanded problem focused interval history; an expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are rovided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient's hospital floor or unit.
• 99226 " ... a detailed interval history; a detailed examination; Medical decision making of high complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient's hospital floor or unit.

Meanwhile, CPT has three new combined codes to streamline the approach to CT imaging of the abdomen and pelvis:

• 74176 -- Computed tomography, abdomen and pelvis; without contrast material
• 74177 -- Computed tomography, abdomen and pelvis; with contrast material(s)
• 74178 -- Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions.

Rule: When the radiologist performs the abdomen and pelvis CT scan at the same setting, you should report the new combined codes 74176-74178. If he performs them alone, you would continue to use the existing pelvis (72192-72194) and abdomen (74150, 74160 and 74170) CTI imaging codes uncombined.