Gastroenterology Coding Alert

7 Coding Facts You Can't Afford to Miss       When billing for Enterra Therapy, as happens with many infrequent or unusual procedures, you may need some specialized knowledge to achieve successful reimbursement.       Enterra Therapy is a treatment indicated for chronic nausea and vomiting associated with gastroparesis when conventional therapies are ineffective. In patients with gastroparesis, food moves through the stomach much more slowly than normal, with consequential severe, chronic nausea and vomiting that is not controllable by usual means. Patients have difficulty eating and may require tube feeding. Enterra Therapy uses a programmable neurostimulator system planted under the skin, plus stimulation leads attached to the stomach. The system is programmed after surgery to deliver small electrical pulses to the stomach. The continuous stimulation contracts the stomach muscle and helps control symptoms.

      You can code this procedure with 64590 (Incision and subcutaneous placement of peripheral neurostimulator pulse generator or receiver, direct or inductive coupling) for placing the equipment, and for the equipment itself, 95972 (Electronic analysis of implanted neurostimulator pulse generator system ...; complex brain, spinal cord, or peripheral [except cranial nerve] neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, first hour). In all cases, it's important that you check your payer's policies for prior authorization and reimbursement, says Vicki Flansburg of the Economic Solutions Group for Enterra Therapy at Medtronic Inc.      When coding for private payers, she says, you should also use 64590 and 95972. Code the general procedure as 64999 (Unlisted procedure, nervous system); this automatically sends the billing into medical review, so you should include the operative report.

      This procedure is not always familiar to insurance payers, both because of the rarity of the condition and the relative newness of this treatment. For successful reimbursement, Flansburg adds, correct diagnostic coding is important. If the condition results from diabetes, for example, use 250.6x (Diabetes with neurological manifestations), then 536.3 (Gastroparesis). Medicare Reimbursement       For Medicare beneficiaries, Flansburg says that Medicare coverage for Enterra Therapy doesn't fall under the usual medical necessity guidelines of being "reasonable and necessary"; the U.S. Food and Drug Administration (FDA) has designated the system as a Humanitarian Use Device/Humanitarian Device Exemption (HUD/HDE). This means that the system is intended to treat or diagnose a disease or condition that affects, or is manifest in, fewer than 4,000 individuals per year in the United States. The HDE is a "determination that a HUD is safe, has probable benefit, and is not considered investigational/experimental." Specifically, the FDAnotice stated that Enterra Therapy is "For treatment of chronic intractable nausea and vomiting, secondary to gastroparesis of diabetic or idiopathic etiology."

      What does this mean to coders? When handling Medicare claims, be sure to submit the proper diagnosis code [...]