Gastroenterology Coding Alert

Formerly unlisted procedure finds identity in latest CPT book

If your office has trouble getting paid for Stretta procedures, CPT 2004 has some good news for you: The temporary assignment of a code for the Stretta procedure is one of several changes CPT has in store for gastroenterology offices in 2004. CPT has also enhanced EGD with ultrasound coding and removed the star (*) from all procedures.
 
Here's a look at the CPT changes that will have the greatest effect on your gastroenterology office.

Stretta Straps Down Temporary Code

In 2004, a treatment for gastroesophgageal reflux disease (GERD) is getting its own code. The Stretta procedure, in which the physician endoscopically inserts electrodes into the lower esophagus, has been added to the Category III code section. In 2004, when a physician performs the Stretta procedure on a patient, report 0057T (Upper gastrointestinal endoscopy, including esophagus, stomach, and either the duodenum and/or jejunum as appropriate, with delivery of thermal energy to the muscle of the lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease).
 
It's a move that will likely make the new year a little happier at practices that perform the procedure. According to Frances Schultz, RN, coordinator of nursing services in the medical procedures unit at the University of Michigan, the new code will make things run more smoothly in her office.
 
Previously, Stretta procedures were coded with 43499 (Unlisted procedure, esophagus) or some other code (or code combination) that Stretta most closely resembled. This made getting paid for Stretta an adventure, not just a job, for a coder.
 
"It was very difficult to get reimbursed for Stretta" in 2003, says Amy Walker, CPC, CCP, insurance supervisor at Gastrointestinal Associates PC in Knoxville, Tenn. "Most insurance companies didn't recognize the technology and wanted to call them 'investigational procedures' or 'experimental.' "
 
When Walker tried to report Stretta using 43499, "reimbursement was little to none," she says. "We won some of them on appeal, but we still lost on others."
 
"Coding Stretta procedures will be much, much easier from now on," Schultz says of the new code. And while a Category III code doesn't guarantee reimbursement, it does put Stretta on track for a Category I CPT code, which guarantees payment.

Track Stretta on the Road to Reimbursement

Due to the newness of the procedure, the Food and Drug Administration will track Stretta safety and efficacy in 2004. If all goes well this year, Stretta is scheduled to be included in CPT 2005 as a Category I code.
 
Getting paid using the new tracking code could still be a problem, however. The Stretta procedure is still considered to be an investigational treatment for GERD.  As such, it is not a reimbursable service for most insurance carriers and Medicare. 
 
The new Category III Emerging Technology code now clearly identifies the procedure as investigational. Some carriers previously paid claims for Stretta procedures when the claims contained CPT Category I codes for a service resembling Stretta.
 
Using the new Category III code, offices may still need to file appeals to receive insurance payment. An advance beneficiary notice (ABN) should be obtained from patients prior to performing the service so they are aware that their insurance may not cover the procedure.  
 
Stretta reimbursement may not be automatic in 2004, but at least now there is a code to represent the procedure, which eliminates a little bit of the doubt when reporting.
 
"Anytime you can have a more comprehensive code, it helps," Walker says. "You want to avoid using an unlisted-procedure code at all costs. They don't show up on fee schedules, and then you're at the mercy of payers."

Clearer EGD Reporting Possible With Changes

CPT has also made esophagogastroduodenoscopy (EGD) with endoscopic ultrasound (EUS) reporting more specific for 2004 - another benefit to coders, according to Walker.
 
"It's the same as the new Stretta code," she says. "Whenever they [CPT] come up with a clarification, it makes it harder to deny the codes and easier to get paid."
 
Previously, CPT designed all the codes that identified EGD with EUS - 43231, 43232, 43242, 43259 - to account for EUS beyond the esophagus and into other areas of the digestive tract.
 
Not all EGDs require EUS past the esophagus, however, so CPT 2004 created two new codes to account for a lesser EUS. From now on, if the physician's notes on an EGD indicate that EUS was only used on the esophagus, choose from the following: