Gastroenterology Coding Alert

CPT® 2017:

PFS to Eye Your EGD Biopsies Payment In 2017

Published on Fri Dec 23, 2016

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Get ready to receive 14 percent less payment for your work on 43239.

As you usher the new year in, get ready for a surprise dip in your payment for the EGD (Esophagogastroduodenoscopy) procedure. Read on for more details on how this change will impact your practice.

CPT^®procedure code 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple) is one of over 40 procedures that will see payment changes under the CY 2017 Physician Fee Schedule.

Caution: While the payment for an EGD procedure performed in a facility will drop by three percent, from $151.45 in 2016 to $146.43 in 2017, the loss for non-facility providers is even more. The payment will dip by a whopping 14 percent from $403.87 in 2016 to $349.20 in CY 2017.

“If a GI practice performs a good number of EGDs then, 14% reduction in reimbursement is significant and practices should be prepared financially,” says Catherine Brink, BS, CMM, CPC, CMSCS, CPOM, president, Healthcare Resource Management, Inc. Spring Lake, NJ

Why all the attention on 43239? “[An] educated guess would be this procedure is coded frequently enough by [gastroenterologists] so that it has come under radar of CMS,” says Brink. “This would mean GI practices must be diligent in their diagnosis coding to show medical necessity for performing EGD.”

The road ahead: Experts suggest viewing this change in perspective of the bigger picture to emerge in 2017 with removal of moderate sedation to affect over 400 procedures. This will also impact GI procedures, but that effect is more widespread rather than just being limited to [this] one single code. If your gastroenterologist administers moderate sedation, then you will have to report a separate code for it so that the total fee does not drop substantially, says Michael Weinstein, MD, former representative of the AMA’s CPT^®Advisory Panel.

To learn more, go to the CMS website: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1654-f.html.

→ CY 2017 PFS Final Rule Impact [ZIP, 13KB]