Gastroenterology Coding Alert

CPT^® 43284-43285 replace the Category III codes 0392T-0393T

Get ready to report two new CPT^® codes for esophageal sphincter augmentation device — a new emerging technology for treatment of GERD (Gastro-Esophageal Reflux Disease) patients. Get to know the essentials about these codes, and how to report them correctly in 2017.

“New CPT^® codes are usually created because there is a need and demand-for-use of these procedures,” says Catherine Brink, BS, CMM, CPC, CMSCS, CPOM, president, Healthcare Resource Management, Inc. Spring Lake, NJ.

Basics: Esophageal Sphincter Augmentation Device is an equipment to improve the function of the Lower Esophageal Sphincter (LES). The provider may place it using a laparoscope. The sphincter augmentation device is a series of magnetic beads linked by a wire that encircle the esophagus just below the LES. The provider customizes and calibrates the device in such a way that it can expand to open LES when the patient swallows, expresses gas or vomit, but remains contracted under normal conditions to prevent acid reflux.

The esophageal sphincter augmentation device is a newer technology intended to solve the problem of LES inadequacy, and thus, GERD, without a more extensive surgical procedure and significant side effects involved with existing procedures such as fundoplasty.

Bury the Old, Welcome the New

Until 2016, these procedures were listed as category III codes listed under emerging technology. They were temporary codes used to allow for data collection specific to emerging technology, services or procedures:

• 0392T (Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device [i.e. magnetic band])
• 0393T (Removal of esophageal sphincter augmen­tation device).

This new year, CPT^® 2017 deletes the above two codes. Now CPT^® has accepted the following procedures for placement in the Category I section in 2017 as follows:

• 43284 (Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device [i.e. magnetic band], including cruroplasty when performed)
• 43285 (Removal of esophageal sphincter augmentation device).

What’s new: The new CPT^® code 43284 also includes cruroplasty, which means that if the patient has a hiatal hernia of up to 3 cm, the surgeon will repair the opening as well by approximating the crura with stitches.

Prove medical necessity to ensure payment: This procedure is a surgical intervention for GERD. However, a provider may decide on a surgical intervention, only if the patient has received no relief from primary measures such as medication and lifestyle changes.

How payers look at it: Because the augmentation device procedure is an emerging technology, some insurers might not yet cover the procedure, or might have strict guidelines for patient’s to qualify.

“Since these procedures will have a true CPT^® code, payers should recognize them and assign a reimbursement amount based on provider contract,” says Brink. “I would report these codes based, as always, on the medical record documentation to support providing these services to receive optimum reimbursement.”

Final takeaway: Make sure you gather information about the diagnostic indicators from the equipment manufacturer representative, and get a copy of the FDA certificate as well. Remember to attach a copy of this FDA document along with your claim, so that the payers know that the procedure is an established one.