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Gastroenterology Coding Alert

CPT Update:

2003 Brings Big Changes to Dilation and Injection Surgery Codes

Published on Sun Dec 01, 2002

The answers to your endoscopy coding problems are finally here: New 2003 CPT codes clarify how to bill properly for several common gastrointestinal procedures including lower gastrointestinal dilations and other endoscopies that include injections

The proposed changes to the CPT manual will go into effect on Jan. 1, 2003.

New Codes Allow Proper Reimbursement for Submucosal Injections

You will no longer be faced with denials of claims for injections performed during endoscopies. Until now, injection codes (90780-90784) were bundled into many of the gastrointestinal endoscopy procedures. According to Linda Parks, MA, CPC, CCP, lead coder at Atlanta Gastroenterology Associates, in the past "all of the procedures that now have new codes were filed either with an unlisted-procedure code or with the base code and a -22 modifier (Unusual procedural services) appended." Physicians always sent a copy of the operative notes and a letter stating the medical need and a comparison of the procedure. Payments were usually delayed, and the reimbursement was poor. Hopefully, the new codes will end any delay and stop physicians from having to send extra paperwork.

Endoscopies that require submucosal injections are usually more difficult and more time-consuming than other endoscopies. The new codes were needed to properly describe in CPT nomenclature the additional time, extra work, and risk to the patient that come with the use of submucosal injections. After Jan. 1, you will be reimbursed properly for these more in-depth procedures. Four new codes are related to endoscopies with injections:

  • 43201 Esophagoscopy, rigid or flexible; with directed submucosal injection(s), any substance, with cross-reference (For injection sclerosis of esophageal varices, use 43204)
  • 43236 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed submucosal injection(s), any substance, with cross-reference (For injection sclerosis of esophageal and/or gastric varices, use 42343)
  • 45335 Sigmoidoscopy, flexible; with directed submucosal injections(s), any substance
  • 45381 Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance.

    Report these codes only once, regardless of the number of injections given. Examples of substances that can be used are India ink, botulinum toxin, saline and corticosteroid solutions.

    You will need to use these new codes under a variety of circumstances. Joel Brill, MD, a gastroenterologist in Phoenix who is the American Gastroenterological Association representative to the CPT Editorial Advisory Committee and the RBRVS Update Committee, describes several scenarios in which these codes will be used.

  • Code 43201: A 75-year-old man with a history of radiation therapy for lung cancer comes to the office because he has difficulty swallowing. After the physician administers conscious sedation, the endoscope is inserted and an esophagoscopy is performed confirming a tight stricture at 31 cm. The endoscope cannot be passed beyond the stricture. A guidewire is placed through the strictured area, the endoscope is withdrawn, and a series of dilators is passed to dilate the stricture. Following endoscopic dilatation, the guidewire is withdrawn. The endoscope is inserted to the level of the stricture, and steroid solution is injected into several sites in the esophageal stricture.

  • Code 43236: A 75-year-old female with weight loss and difficulty swallowing is referred to the gastroen-terologist for evaluation. Her primary-care physician had ordered a barium swallow and upper GI x-ray that revealed a markedly dilated esophagus with a "bird's beak" tapering near the gastroesophageal junction consistent with a diagnosis of achalasia. After discussion with the patient, the decision is made to proceed with an upper gastrointestinal endoscopy. After the physician administers conscious sedation, the endoscope is inserted through the mouth into the esophagus. After the doctor inspects the remainder of the stomach and proximal duodenum to confirm the absence of any co-existing mucosal abnormality, the endoscope is withdrawn into the distal esophagus. Botulinum toxin type A is injected using a sclerotherapy needle into the lower esophageal sphincter area.

  • Code 45335: A 68-year-old male presents in the office and subsequently has a large sessile polyp endoscopically removed from the mid-sigmoid colon. The polyp is removed because it has been shown to contain adenocarcinoma. After an enema prep, a flexible sigmoi-doscopy is performed to inject sterile India ink using a sclerotherapy needle into the scar to allow identification of the site by the surgeon. The sclerotherapy needle is withdrawn, and the physician observes the site for signs of bleeding. The flexible sigmoidoscope instrument is then withdrawn.
  • Code 45381: A 68-year-old male had undergone a colonoscopy for the evaluation of occult blood-positive stool, where a 2-cm adenomatous sessile polyp in the transverse colon was identified and removed. Pathologic examination showed evidence of adenocarcinoma extending to the line of resection. After appropriate preparation and physician administration of conscious sedation, a colonoscopy is performed. The previous site of polyp removal in the transverse colon is identified, and the physician injects sterile India ink into the site of the previous polyp resection, using a sclerotherapy needle, which allows the surgeon to identify the site for surgical resection.

    Add Dilation Codes to Lower GI Endoscopies

    In the past, upper GI endoscopies were the only gastrointestinal endoscopies to have dilation procedures included in their codes. The question has often come up regarding how to code for the same type of lower GI endoscopies with dilation. Most gastroenterologists simply billed by using an unlisted-procedure code. Finally, the AMA has added dilation codes to the colonoscopy and sigmoidoscopy series:

  • 45340 Sigmoidoscopy, flexible; with dilation by balloon, 1 or more strictures
  • 45386 Colonoscopy, flexible, proximal to splenic flexure; with dilation by balloon, 1 or more strictures (A cross-reference tells you not to report 45340 with 45345, or 45386 with 45387, since pre-dilation is included in these stent placement codes)
  • Report these codes for each stricture that is dilated.

    Suppose you see a 72-year-old man who has previously had a low anterior resection for a rectal adenocarcinoma. He has developed symptoms of constipation. After an enema prep, the flexible sigmoidoscope is passed to 10 cm where an anastomotic stricture is identified. A 15-mm through-the-scope balloon is passed by the physician through the flexible sigmoidoscope channel and placed across the strictured segment. The stricture is dilated under direct visualization. The balloon is deflated and is removed from the endoscope. You would code 45340 for this procedure, Brill says.

    In another case, a 65-year-old female with crampy abdominal pain and a history of a colon resection undergoes a barium enema, which reveals a transverse colon stricture at the site of the previous colonic anastomosis. After appropriate preparation and physician administration of conscious sedation, a colonoscope is passed to the area of the stricture. A 15-mm through-the-scope dilating balloon is passed through the colonoscope and positioned across the area of narrowing. The stricture is dilated, the balloon is deflated, and the colonoscope is then passed to the cecum. The colonoscope is then withdrawn. In this case, use 45386 for the procedure.

    Other Modifications

    You can no longer use a separate five-digit code in place of a modifier. For example, you cannot substitute code 09925 for modifier -25. This rule has been applied to all of the modifiers. Also, a new modifier has been added: modifier -63 (Procedure performed on infants less than 4 kg). This change was made because procedures performed on low-body-weight infants are more complex than other procedures. This modifier is to be used on codes 20000-69999 only, not on E/M or Medicine codes.

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