Gastroenterology Coding Alert

Although gastroenterologists were initially pleased with the creation of several new CPT codes for endoscopic ultrasound, these codes no longer permit separate reporting of radiological supervision and interpretation services. The lack of a separate radiological code and the lower relative value unit (RVU) assigned by HCFA to some of the new codes has decreased Medicare reimbursement for an endoscopic ultrasound (EUS) with fine needle aspiration/biopsy (FNA/B) performed in the upper gastrointestinal tract. This has caused some gastroenterologists to delay reporting the new codes. The new rectal EUS codes, however, offer superior Medicare reimbursement over the old codes and are being used immediately.

No Separate Radiological Code to Report

In CPT 2000, 43259 (upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with endoscopic ultrasound examination) was the only EUS code available and could only be used to report upper gastrointestinal procedures. In addition, the code covered only the ultrasound portion of the procedure and did not include the fine needle biopsy or aspiration that is often performed during the EUS.

In response to complaints from gastroenterologists, CPT 2001 created the following new codes for EUS and EUS with FNA/B:

43231 esophagoscopy, rigid or flexible; with endoscopic ultrasound examination

43232 ... with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s)

43242 upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s)

45341 sigmoidoscopy, flexible; with endoscopic ultrasound examination

45342 ... with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s)

Each of these new codes contains a cross-reference at the end of the definition that states, do not report 76975 [gastrointestinal endoscopic ultrasound, supervision and interpretation] in conjunction with the EUS procedures. The old EUS code, 43259, still contains a cross-reference at the end of its definition that allows the separate reporting of the radiological supervision and interpretation code.

Use CPT 2000 Codes for Upper GI EUS With FNA/B

The end result of these new codes and the RVUs that have been assigned to them is that reimbursement for an upper gastrointestinal endoscopy with EUS and FNA/B is lower with the new CPT 2001 codes. You now get paid more for doing a [surgical] PEG tube placement [43750] than for an ultrasound examination, says Roy Ligresti, MD, director of endoscopic ultrasound at New York Medical College in Valhalla, N.Y.

Under CPT 2000 guidelines, Ligresti would have billed an upper gastrointestinal endoscopy with EUS and FNA/B by reporting 43259, which has an RVU of 7.79, and 76975-26 (professional component), which has an RVU of 1.15, for a total of 8.94. He would receive no extra reimbursement for the FNA portion of the procedure. With CPT 2001, the upper gastrointestinal endoscopy with EUS and FNA is reported with code 43242, which has an RVU of 7.83. At the 2001 Medicare conversion factor of $38.2581, gastroenterologists are losing about $42 for this procedure.

Because there was no specific code for an EUS with FNA/B in CPT 2000, some gastroenterologists billed other coding combinations that included 76942 (ultrasonic guidance for needle placement) and/or 43239 (upper gastrointestinal endoscopy with biopsy). The reimbursement for most of those coding combinations, however, is still greater than what will be paid for the new CPT 2001 code (43242).

Maurits Wiersema, MD, FACP, FACG, a gastroenterologist and associate professor of medicine at the Mayo Clinic in Rochester, Minn., and the American Society of Gastrointestinal Endoscopists (ASGE) representative to the CPT Editorial Advisory Panel, confirms that the ASGE is trying to get HCFA to address these inequities in reimbursement and hopes there will be a resolution to this problem in the next few weeks. After March 31, 2001, these new codes must be used for claims. In the interim, the ASGE has taken the position that use of the codes should be determined by the individual practice, [its] prior reimbursement experience and anticipated reimbursement with the new CPT descriptors, he says.

Note: The RVUs cited in this article apply to Medicare claims only. Gastroenterologists should contact their commercial insurers to find out what reimbursement they plan to offer for these new codes.

Most commercial insurers also use HCFAs deadline of March 31, according to Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. She adds that sometimes it takes several months for the payer to input the new codes into its computer systems. Sometimes a claim with a new code will be denied because the payers computer doesnt recognize the new code, she says. If a claim with 43242 is denied prior to April 1, gastroenterologists may refile using the CPT 2000 codes.

Coding for Rectal EUS Procedures

To make matters even more confusing, some of the new rectal EUS codes offer better Medicare reim-bursement than what gastroenterologists were probably previously receiving. The rectal EUS code offers an opportunity to improve reimbursement relative to the prior method of coding, and therefore we [ASGE] would recommend its use, Wiersema says.

Prior to CPT 2001, Ligresti would report a flexible sigmoidoscopy with EUS with codes 45330, which has an RVU of 1.39, and 76975-26, which has an RVU of 1.15, for a total of 2.54. (He would use the same codes to report a flexible sigmoidoscopy with EUS and FNA/B.) Under CPT 2001, 45341 the new code for a flexible sigmoidoscopy with EUS has an RVU of 5.36. Code 45342, the new CPT code for a flexible sigmoidoscopy with EUS and FNA, has an RVU of 6.18.

For more information on using the new CPT 2001 EUS codes, see page 89 of the December 2001 Gastroenterology Coding Alert.