Gastroenterology Coding Alert

As a general rule, Medicare does not provide additional reimbursement for supplies or services that are considered to be a standard part of a gastrointestinal procedure. But gastroenterologists may be able to bill Medicare and private insurers for surgical supplies and drugs used for some endoscopic procedures performed in an office setting.

Recently, Saul Rosnoff, MD, a gastroenterologist in Los Angeles, asked, What supplies, instruments and facility charges can I bill private insurers when performing endoscopies and colonoscopies in the office? We do bill for a surgical tray (code A4550 or 99070), however, the reimbursement for these codes does not cover our costs.

The Correct Coding Initiative (CCI) states that all services integral to accomplishing a procedure will be considered included in that procedure and, therefore will be considered a component and part of the comprehensive code.

CCI specifically notes that certain generic services are integral to a standard medical/surgical service and thus are not reimbursable separately. These include:

- insertion of intravenous access for medication;
- sedative administration by the physician performing the procedure (conscious sedation);
- surgical supplies, unless accepted by existing Health care Financing Administration (HCFA) policy; and
- endoscopic procedures reimbursed by Medicare.

But this CCI policy does not apply to several endoscopic procedures, including upper gastrointestinal endoscopies (43234-43259), that have an applicable supply code, which can be billed separately if the procedure is performed in an office setting, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. When Medicare was setting the professional fees for these procedures, it did not take into account the cost of supplies that the gastroenterologist would incur because these services typically are performed in an outpatient hospital setting.

Gastroenterologists also may bill for the drugs used for conscious sedation. Although Medicare doesnt reimburse for the administration of conscious sedation, Terry Fletcher, CPC, CCS-P, a healthcare coding consultant in Laguna Beach, Calif., has seen her California clients get paid for drugs such as Versed or Demerol. The HCPCS code for each sedative used should be added to the claim, she recommends.

Editors note: For more on the billing of conscious sedation to private insurers, please refer to the December 1999 Gastroenterology Coding Alert article Get Reimbursed for Conscious Sedation From Private Insurers on page 29.

Private Insurers May Pay for Supplies

Although Medicare does not provide extra reimbursement for services and supplies that are an integral part of the procedure, some private insurers will. The CPT code for a surgical tray (99070) states that these are for supplies and materials provided by the gastroenterologist over and above those usually included with the office visit, Callaway-Stradley points out.

Margaret Stewart, billing supervisor for the Metro-politan Gastroenterology Group, an eight-physician practice in Washington, D.C., has found that some private insurers will reimburse for surgical supplies. In her practice, flexible sigmoidoscopy is the only endoscopic procedure done in an office setting, and she uses code 99070 to bill private insurers for a surgical tray in addition to the procedure itself.

Some commercial insurers will pay for a surgical tray, says Stewart. She estimates the actual reimbursement is approximately 75 percent of what the
gastroenterologist bills.

Discuss With Each Insurer

Another approach that Callaway-Stradley recommends to her clients is to establish good communications with the top five insurance companies in your practice and any with which you have major contracts. Ask them if they pay for supplies and how they want them billed, she explains. And if you find that youre losing money because of the supplies, then you might want to consider not working with those companies.