Gastroenterology Coding Alert

You’ll reduce the amount of times you use modifier 52 for GI procedures.

If you want to avoid headaches starting in the new year, then you need to immerse yourself in the significant changes to coding for lower GI endoscopic procedures in CPT® 2015. These changes are consistent with similar changes made to upper GI endoscopy codes in CPT® 2014. These revisions also conclude a concerted effort to standardize the terminology of the GI endoscopy codes.

Descriptor Edits Changes the Way You Will Report GI Procedures 

The CPT® Editorial Panel continues to standardize the language and make the code descriptors more accurate in lower GI endoscopy procedures. This will affect codes across the lower GI spectrum with changes in:

Base codes: The panel has continued with the standardization of the code descriptor by replacing the terminology “with or without” in the codes with “including, when performed.” This is similar to what was done to upper GI procedures (see “CPT® 2015 Part 1: Non-Inclusive Diverticulitis Drives New Esophagoscopy Changes” featured in the Gastroenterology Coding Alert volume 16 number 11). This particular change is applicable for the base codes of endoscopy families.

• Code 44360 gets updated from “Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)”  to “Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)”
• Similarly, code 44380 will read as “Ileoscopy, through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)”
• Code 44385 will be described as “Endoscopic evaluation of small intestinal pouch (eg, Kock pouch, ileal reservoir [S or J]); diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)”
• Code 44388 for stomal colonoscopy will now read as “Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)”
• Code 45330 updates to “Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)”
• Code 45378 will read as “Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure).

Keep in mind that the changes in descriptor language do not affect the usage the above codes in any way. The changes are just a continuation in standardization of the language. 

Foreign body removal: You also have to implement descriptor changes for removal of foreign body, which effectively specifies that from next year onward, you will be reporting foreign body removal only once even if the physician removed multiple bodies in the same session. Code 45332 will change to “Sigmoidoscopy, flexible; with removal of foreign body[s].” Similar changes will affect 44363 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of foreign body[s]), 44390 (Colonoscopy through stoma; with removal of foreign body[s]), and 45379 (Colonoscopy, flexible; with removal of foreign body[s]).

Control of bleeding: The panel has replaced all previous code descriptors for control of bleeding codes (such as injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, and plasma coagulator) with a single term “any method.” For example, 44391 will change to “Colonoscopy through stoma; with control of bleeding, any method.” Similarly updated codes are 45334 (Sigmoidoscopy, flexible; with control of bleeding, any method) and 45382 (Colonoscopy; with control of bleeding, any method).

Stent placement: The new lower GI endoscopy codes for placement of endoscopic stents will now include pre-dilation, post-dilation, and guide wire passage, whereas you currently consider only pre-dilation. You will not report modifier 52 (Reduced services), even if the GI does not perform all the three components during the same session and you will not be allowed to report these separately also. All old stent related codes stand deleted and new codes reflecting the change have been introduced instead. For instance, CPT® deletes 44383 and replaces it with new code 44384 (Ileoscopy, through stoma; with placement of endoscopic stent [includes pre- and post-dilation and guide wire passage, when performed]) takes its place. Similarly, 44402 will replace 44397 (Colonoscopy through stoma; with transendoscopic stent placement [includes predilation]); 45347 will replace 45345 (Sigmoidoscopy, flexible; with transendoscopic stent placement [includes predilation]); and new code 45389 replaces 45387 (Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic stent placement [includes predilation]).

Ablation: New codes for ablation procedures follow the same changes done to stent procedures and will include pre- and post-dilation and guide wire passage, when performed. Separate reporting of pre- or post-dilation or guide wire passage will be rejected due to bundling. For instance, you will delete 44393, and you’ll add new code 44401 (Colonoscopy through stoma; with ablation of tumor [s], polyp[s], or other lesion[s] [includes pre-and post-dilation and guide wire passage, when performed]). Similarly, new codes 45346 and 45388 replace 45339 (Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique)  and 45383 (Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique) respectively.

Bipolar cautery: CPT® 2015 has also modified tumor removal codes by taking out the reference to “bipolar cautery.” For example, 44392 will become “Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps” in accordance with the latest techniques being used for growth removal. Similar modifications can be seen to 45333 (Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps) and 45384 (Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps). Therefore, from January onward, you will have to use codes for unlisted procedures to report use of bipolar cautery.

New Introductions in Colonoscopy Codes Expands the Family

The CPT® Editorial Panel has now defined colonoscopy as the examination of the whole colon because CPT® 2015 removes the phrase “proximal to splenic flexure” from the official descriptor for code 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression [separate procedure]), which indicates the procedure applies to the entire colon, rather than just a specific portion.

Other than changing the descriptors of the existing codes, CPT® 2015 introduces new codes for transendoscopic balloon dilation and endoscopic mucosal resection. So, if your physician performs a simple endoscopy and has to use balloon dilation for the simple purpose of better visualization, you will be able to report this new code 44381 ( Ileoscopy,through stoma; with transendoscopic balloon dilation). CPT® 2015 has introduced a similar code for colonoscopy 44405 (Colonoscopy through stoma; with transendoscopic balloon dilation).

Get ready for new codes describing endoscopic mucosal resection (EMR) including injection-assisted, cap-assisted, and ligation-assisted techniques. CPT® has now bundled sub-mucosal injection, banding, or snare polypectomy for the same lesion into the code for EMR. Moreover, you will not report a biopsy if your gastroenterologist performs it on the same lesion as the EMR. The new codes are 44403 (Colonoscopy through stoma; with endoscopic mucosal resection), 45349 (Sigmoidoscopy, flexible; with endoscopic mucosal resection), and 45390 (Colonoscopy, flexible; with endoscopic mucosal resection).

Colonoscopy via stoma has been brought at par with flexible colonoscopy with new codes for area-specific ultrasound procedures (with/without fine needle aspiration/biopsy). The new code for colonoscopy via stoma is 44406 (…with endoscopic ultrasound examination, limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures). The corresponding flexible colonoscopy code 45391 has been updated to “…with endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures.”

CPT® 2015 has recognized decompression procedures in endoscopies by adding new codes in colonoscopy (flexible and through stoma) and modifying an existing one in sigmoidoscopy. The new codes are 44408 (Colonoscopy through stoma; with decompression [for pathologic distention] [eg, volvulus, megacolon], including placement of decompression tube, when performed) and 45393 (Colonoscopy, flexible; with decompression [for pathologic distention] [eg, volvulus, megacolon], including placement of decompression tube, when performed). The modified sigmoidoscopy code 45337 will be used as “Sigmoidoscopy, flexible; with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed.” 

Provision for Unlisted Procedures Keeps Space for Emerging technology 

CPT® 2015 has kept a provision for unlisted procedures for procedures not yet coded. You will find that 44799 (Unlisted procedure, small intestine) will now be much more specific with the code being confined to the small intestine. A similar area-specific unlisted procedure has been added with 45399 (Unlisted procedure, colon).