Gastroenterology Coding Alert

Cut out unnecessary steps when reporting endoscopic marking clips.

When the GI physician encounters bleeding during an endoscopy or colonoscopy, they may use gastro clips (also called endoclips) to control blood flow. Use these tips to master the delicate uncertainties of clip placement coding and get the maximum amount of reimbursement for your physician services.

Tip 1: Get a Grip On the Clip Basics

Here’s what clips are: Endoclips are small metallic devices that gastroenterologists use to treat bleeding lesions (hemostasis) such as ulcers, vascular malformations, small bleeding arteries, polypectomy sites, diverticula in the colon, or mucosal defects.

During clip placement, the physician places the clip via an endoscope, and once deployed, the clips can remain in place for several days to weeks. Once the mucosa heals, the clips will eventually and spontaneously detach and pass undetected in the stool. Clip devices are also used to accomplish approximation of tissues after removal of larger polyps.

For example, the gastroenterologist applies the clip with pressure onto the target tissue and has a technician close it manually by squeezing the catheter handle assembly. The clips are used during various procedures, including colonoscopies, esophagoscopies, and sigmoidoscopies.

Tip 2: Highlight These Hemostasis Codes

Gastroenterologists typically use clips as a control-of-bleeding or hemostasis devices. Therefore, whenever you spot a clip application mentioned in the physician’s documentation, you should keep these procedure codes handy, depending upon the location of the clip placement:

Esophagoscopy:

• 43227 (Esophagoscopy, flexible, transoral; with control of bleeding, any method)

EGD:

• 43255 (Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method)

Enteroscopy:

• 44366 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator))
• 44378 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator))

Sigmoidoscopy:

• 45317 (Proctosigmoidoscopy, rigid; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator))
• 45334 (Sigmoidoscopy, flexible; with control of bleeding, any method)

Colonoscopy:

• 44391 (Colonoscopy through stoma; with control of bleeding, any method)
• 45382 (Colonoscopy, flexible; with control of bleeding, any method)

Example: Your gastroenterologist performs a video esophagogastroduodenoscopy (EGD) with proximal jejunum enteroscopy, using a clip and BICAP cautery, as well as performing biopsies. The patient had a 2-mm bleeding arteriovenous malformation (AVM) in the proximal jejunum that the physician controlled by ablation with BICAP cautery and with a tri clip application.

You may start thinking of multiple codes to report this scenario, but you should pause. As the gastroenterologist used all of these modalities to accomplish one goal — basically, the treatment of bleeding AVMs (hemostasis/occlusion) — you should use only one code (43255).

Tip 3: Make Provisions for Tissue Marking Clips

If your gastroenterologist uses a clip for endoscopic tissue marking, you won’t find any specific CPT® codes for this service. You will have to use an unlisted-procedure code such as 43499 (Unlisted procedure, esophagus), 44799 (Unlisted procedure, small intestine), or 45399 (Unlisted procedure, colon) depending on the area where the physician places the clip.

No standard fee exists for unlisted-procedure codes. Rather, payers consider claims on a case-by-case basis, so the success of any unlisted-procedure claim depends largely on the documentation you submit with your claim.

What to do: You should submit full documentation with every unlisted-procedure claim. To improve your reimbursement chances, you should include these documents, whenever possible:

• Show a calculation of your charges for the unlisted-procedure code. Because unlisted-procedure codes do not have any associated payment, you must identify the amount of reimbursement you wish to be paid. Be prepared to accept less than 100 percent of your billed amount from the payer.
• Give a detailed description of the procedure performed by your gastroenterologist and skip overt medical jargon and confusing terminology.
• For enforcing your claim, include some comparison with procedures that have an existing CPT® code that requires similar work and resources. This may get better traction with the insurer while deciding the claim.
• For facility bleeding for the clip, you should include an invoice for the supply cost to justify the extra payment.

Tip 4: Prepare for Clip as Secondary Procedure

If the clip procedure is an added closure method secondary to another procedure, payers may consider the clip application inherent in the primary procedure.

But if the physician uses a clip during a separate procedure at a different encounter or different day (such as placing a clip for closure of a bleeding site two days after a polypectomy), you can code this service separately — but only if the clipping is the only closure method the physician uses. Again, you’ll use an unlisted-procedure code (43499, 44799, 45399) for this procedure.