Gastroenterology Coding Alert

Cut out unnecessary steps when reporting endoscopic marking clips.

Has your gastroenterologist performed a control of bleeding procedure during an endoscopy or colonoscopy? If so, then you are probably no stranger to the terms “endoclips” or “gastro clip,” You may have also come across such clip application in other procedures. Use these tips to master the delicate uncertainties of clips placement coding and get the max for your physician services.

Tip 1: Get a Grip On the Clip Basics

“Endoclips are small metallic devices that the gastroenterologists use to treat bleeding lesions (hemostasis) such as ulcers, vascular malformations, small bleeding arteries, polypectomy sites, diverticula in the colon, or mucosal defects,” informs Michael Weinstein, MD, Vice President of Capital Digestive Care. The physician places the clip through 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 Hemostatis 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 performed a video esophagogastroduodenoscopy (EGD) with small bowel enteroscopy, using a clip and BICAP cautery as well as performing biopsies. The patient had a 2-mm bleeding arteriovenous malformation (AVM) in the distal duodenum that the physician controlled by ablation with BICAP cautery and with a tri clip application. Also, the patient had a 1-mm AVM in the proximal jejunum that the gastroenterologist ablated with BICAP cautery. 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),” adds Weinstein.

Tip 2: 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, 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.

Tip 3: Prepare for Clip as Secondary Procedure

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

But if the physician uses a clip during a separate event (such as placing a clip for closure of a perforation 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.