Gastroenterology Coding Alert

Understand when to use an unlisted-procedure code.

GI physicians use endoclips to control or prevent bleeding in a variety of clinical situations. Accounting for this and reporting the correct codes can lead to a lot of uncertainty for coders, however.

If you’re feeling stuck when it comes to the correct codes, here’s a helpful guide to help your clip coding confidence.

Remember What the Clips Do

Endoclips are small devices that gastroenterologists use, particularly in endoscopy. They are designed to close off tissue within a body, such as blood vessels or other structures, to prevent bleeding or to seal off an area. They are often used during surgical procedures or in the treatment of gastrointestinal bleeding.

For example, a gastroenterologist will apply the clip with pressure onto the target tissue and have a technician close it manually by squeezing the catheter handle assembly. The clips are used during various procedures, including colonoscopies, upper GI endoscopy, and sigmoidoscopies.

During clip placement, the physician places the clip via an endoscope, and once deployed, the clips can remain in place for several days to weeks. Once the mucosa heals, the clips will eventually detach and pass undetected in the stool.

Keep These Hemostasis Codes Handy

One of the primary uses of gastro clips is to control bleeding. They can be used to stop active bleeding or to prevent potential bleeding from a high-risk lesion. Whenever you spot a clip application mentioned in the physician’s documentation, you should keep these procedure codes handy, depending upon the location of the clip placement:

Esophagoscopy:

• 43227 (Esophagoscopy, flexible, transoral; with control of bleeding, any method)

Esophagogastroduodenoscopy (EGD):

• 43255 (Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method)

Enteroscopy:

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

Sigmoidoscopy:

• 45317 (Proctosigmoidoscopy, rigid; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator))
• 45334 (Sigmoidoscopy, flexible; with control of bleeding, any method)

Colonoscopy:

• 44391 (Colonoscopy through stoma; with control of bleeding, any method)
• 45382 (Colonoscopy, flexible; with control of bleeding, any method)

Don’t Let the Procedure Details Bog You Down

The procedure notes are supposed to be packed with details, but that can sometimes mean you have a difficult time deciding what information to use when finding the correct GI procedure code.

Example: Let’s say your gastroenterologist performs an EGD with proximal jejunum enteroscopy using a clip and BICAP cautery, as well as performing biopsies. The patient has a 2 mm bleeding arteriovenous malformation (AVM) in the proximal jejunum that the physician controls by ablation with BICAP cautery and with a clip application.

Before you panic, take a closer look at the procedure. This sounds much more complicated of a coding situation than it really is. As the gastroenterologist used all of these modalities to accomplish one goal — basically, the treatment of bleeding AVMs (hemostasis/occlusion) — you should use only one code: 43255.

Use Unlisted Codes for Marking

Another common use of endoclips is for marking a specific area in the gastrointestinal tract. This can be helpful in procedures where a specific area needs to be revisited or identified in future procedures or imaging.

The tricky thing here is that there aren’t any specific CPT^® codes for this service. So, when your gastroenterologist uses a clip for endoscopic tissue marking, turn to an unlisted-procedure code such as 43499 (Unlisted procedure, esophagus), 44799 (Unlisted procedure, small intestine), or 45399 (Unlisted procedure, colon) depending on the area where the physician places the clip.

Documentation alert: Documentation is vital to reimbursement for these cases because no standard fee exists for unlisted procedure codes. Rather, your payers will consider claims with unlisted procedure codes on a case-by-case basis, and they determine payment based on the documentation you provide. Unfortunately, claims reviewers frequently do not have a high level of medical knowledge, and physicians don’t always dictate the most informative notes.

If the person making the payment decision doesn’t understand what the physician did, your reimbursement probably won’t properly reflect the effort involved, says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare in Tinton Falls, New Jersey.

What to do: To improve your chances of being reimbursed for an unlisted procedure, you should include the following information whenever possible:

• Detailed procedure report: This should describe the procedure performed, including how it was performed and the reason for the clips. It should also include detailed information of any complications or additional relevant information. Be sure to use as much common language as possible and avoid too much medical jargon.
• Medical necessity: While this information should be part of the procedure report, be sure to separate out or otherwise highlight all the details that will contribute to the payer’s understanding of the clip placement being medically necessary. “Add comment to the claim such as ‘application of endoclip for tissue marking,’” advises Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel advisor for ASGE in Pasadena, California. “Unlisted codes will likely be denied, but providing this information usually prompts a request for more documentation rather than a flat denial. Doing this is therefore more streamlined than starting an appeal or starting all over,” he says.
• Calculation of charges: Because unlisted-procedure codes do not have any associated payment, you must identify the amount of reimbursement you wish to be paid. It might be wise to include comparative codes to help justify the cost and complexity of the unlisted procedure. However, be prepared to accept less than 100 percent of your billed amount from the payer. For facility costs for the clip, you should include an invoice for the supply cost to justify the extra payment.