Gastroenterology Coding Alert

Gastroenterologists often use India ink tattooing to mark lesions for easy identification, but many face problems when billing for the procedure. Such claims are more likely to be reimbursed by private payers if gastroenterologists document the procedure thoroughly and accurately support the claims with the purpose for tattooing the lesion.

The procedure consists of using a needle to inject India ink into a lesion and permanently marking it so that a gastroenterologist can easily identify it later. I use it to see if a polyp has been removed completely, says Bergein F. Overholt, MD, FACP, MACG, past president of the American Society for Gastrointestinal Endoscopy. Often when taking off a sessile polyp, its difficult to see if you got it entirely. So you use India ink tattooing to mark the site of the polyp, then go back and biopsy the site later.

No CPT Code Exists

Despite its value to the patient, India ink tattooing is not considered by Medicare to be a reimbursable service. There is no specific CPT code for the procedure, and according to the Correct Coding Initiative (CCI), the identification of anatomical landmarks is one of many generic services for which
it would be inappropriate to separately codebased on standard medical and surgical principles.

While acknowledging that many in gastroenterology may not interpret the phrase identification of anatomical landmarks to include India ink tattooing, Pat Stout, CMT, CPC, an independent gastroenterology coding consultant in Knoxville, Tenn., explains that this is one of many added services that gastroenterologists provide to their patients for which they often dont get reimbursed.

There is a menu of services gastroenterologists perform that should be reimbursed but lack a specific code to bill the service, she explains. Lesion marking is one of these. Although Medicare providers in general will not reimburse for the procedure, both Overholt and Stout agree that some private payers may if you:

1. use codes for unlisted procedures;
2. appeal denials; and
3. follow payer instructions.

Use Miscellaneous Code

When billing for India ink tattooing, Stout recommends listing the code for the base endoscopy procedure, followed by the unlisted code for the site of the body being tattooed. To code for the marking of lesions during a colonoscopy, for example, list 45378 (colonoscopy) first and then 44799 (unlisted procedure, intestine).

A description of the tattooing procedure must accompany the claim, emphasizes Stout. Unless a description of the procedure and the purpose for doing the tattooing is attached, the claim is no good, she says. The documentation has to support the service.

Letter of Appeal May Overturn Denial

For a while, Overholt systematically was appealing any denial by private insurers of India ink tattooing claims. In a separate letter, he would present cost estimates of the tattooing procedure, which included materials and supplies used as well as the additional nursing time required. He would recommend a reimbursement of $100 and end the letter by stating that he was willing to discuss this matter further with the payer.

India ink tattooing is a very valuable technique that takes time, carries some risk of infection and has a cost to it, he says in explaining why he decided to pursue these appeals. It should be reimbursed.

Although appealing a denial is time consuming, Overholt feels it did help win reimbursement from private payers. And once the payers agreed to an initial reimbursement, Overholt believes that they tended to automatically honor other lesion-marking claims in subsequent billings.

Follow Payer Instructions

If a payer, whether Medicare or a private insurer, has indicated in writing its reasons for not reimbursing India ink tattooing, however, gastroenterologists should stop coding for the procedure with that particular payer, says Stout. If a local Medicare payer has put in writing that it will not reimburse and you continue to bill for that service, you could be flagging your practice for an audit, she cautions.

Gastroenterologists need to follow the specific instructions of each payer. As with all these procedures that require the use of an unlisted code, Stout notes. The best thing a gastroenterologist could do is write the payer and ask them to tell you what to do.