Gastroenterology Coding Alert

Endoscopic ultrasound is one of several gastrointestinal procedures for which there may not be a specific CPT code, depending on the part of the intestinal tract where the procedure is being performed. Gastroenterologists may have to choose between using an unlisted code and modifier -22 (unusual procedural services) to report the procedure.

In endoscopic ultrasound, an ultrasound device is attached to the end of the endoscope in addition to the standard endoscopic camera. Once the endoscope is passed into the gastrointestinal tract, ultrasound images will appear instantaneously on a monitor situated near the gastroenterologist, which allows him or her to obtain structural information about the gastrointestinal tract. Ultrasound, also referred to as echography, sonography and ultrasonography, also can be used by a gastroenterologist to guide the insertion of a biopsy needle into a tumor or lesion.

Use 43259 for Upper GI Procedures

Endoscopic ultrasound is made up of two components: the endoscopic procedure used to insert the ultrasound device into the body and the use of the ultrasound itself. When the gastroenterologist performs an endoscopic ultrasound in the upper gastrointestinal tract, then code 43259 (upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with endoscopic ultrasound examination) should be used to report the procedure, according to Michael Weinstein, MD, gastroenterologist in Washington, D.C., and a representative to the American Medical Association (AMA) CPT advisory panel. The endoscopy, however, must include the examination of the esophagus, stomach, and either the duodenum or jejunum as appropriate, stresses section 15100.A of the Medicare Carriers Manual.

Coding Lower GI Procedures

Although endoscopic ultrasound also is performed on other areas of the gastrointestinal tract, such as the colon and rectum, there are currently no specific CPT codes to cover those procedures. Gastroenterologists may report the base endoscopic procedure, says Weinstein, with modifier -22 attached. If a rectal ultrasound is performed during a colonoscopy, then code 45378 (colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]) could be reported with modifier -22 attached to it.

When attaching modifier -22 to a procedure code, Medicare and most commercial insurance companies require two separate pieces of documentation be submitted along with the claim. The first is a copy of the operative note for the procedure, which documents the unusual difficulty of the case. The amount of time the procedure took should be noted in the report.

There also should be a letter from the gastroenterologist explaining how the service differs from the usual endoscopic procedure and why extra reimbursement is being requested. The gastroenterologist might even want to compare the endoscopic ultrasound to similar procedures that have their own CPT codes.

Local Payers May Not Need Specific CPT Code

Weinstein also suggests that gastroenterologists may want to contact their local payers and inquire about the local coding policy for endoscopic ultrasound. Many payers will explain how they want to be billed and then reimburse you, states Weinstein. Some payers dont need to have a specific CPT code to pay for a procedure.

National Heritage Insurance Company, the Medicare Part B carrier for Maine, Massachusetts, Vermont and New Hampshire is an example of a provider that is willing to reimburse unlisted codes. It has a specific medical policy covering endoscopic ultrasound procedures in the lower gastrointestinal tract. This policy states that 91299 (unlisted diagnostic gastroenterology procedure) should be used to report the procedure. Code 76999 (unlisted ultrasound procedure) should be used to report the radiological supervision and interpretation of the ultrasound.

Code Radiological Supervision and Interpretation

Although code 76999 is not included specifically in Medicares national payment policy for this procedure, it and many commercial insurance companies do allow a radiological supervision and interpretation service to be billed with this procedure if performed by the gastroenterologist. Although the ultrasound image is present while the gastroenterologist is performing the endoscopy, it also can be saved and reviewed on a later day, according to Weinstein. Some gastroenterologists are not trained or comfortable reading their own sonographic pictures, he says. So many of them will do the procedure, take the pictures and ask a radiologist to look at them.

Medicares national policy does say it will reimburse for this service, and the carriers manual states that [i]nterpretation, whether by a radiologist or endoscopist, is reported under CPT code 76975-26 (gastrointestinal endoscopic ultrasound, radiological supervision and interpretation). The modifier -26 (professional component) represents the gastroenterologists interpretation of the test results.

Some local Medicare payers and commercial insurance companies may not reimburse a gastroenterologist for interpretation of the results because they consider the interpretation included in code 43259 since the ultrasound image is available to the gastroenterologist during the endoscopy. Many of the state Medicare medical directors probably believe that the interpretation is part of the procedure, but that will vary from carrier to carrier, says Weinstein.

Nationwide Insurance, the Medicare carrier in Ohio and West Virginia, distinguishes between the supervision of the ultrasound and its interpretation. Only when both services are provided by same provider, can they be billed by using only code 76975-26.

The local medical review policy for the use of endoscopic ultrasound in the upper gastrointestinal tract states that if the radiologist is performing only the interpretation and the endoscopist is performing only the supervision, each should bill 76975-26 with the -52 modifier (reduced services). The policy goes on to say that both codes 43259 and 76975-26 may be reported on the same day.

Because coverage issues and reimbursement for this procedure will vary dramatically among payers, gastroenterologists should contact their local payers for specific coding instructions.