Gastroenterology Coding Alert

PDT is an arduous procedure for a patient, and it can be a frustrating challenge for coders. Mary Garner, CPC, CCP, of Gastrointestinal Associates PC in Knoxville, Tenn., says much of the difficulty lies in the length of the procedure and all the variables present in each individual claim.
 
"[Gastroenterologists] use light application to ablate normal tissue, used in conjunction with an esophagoscopy along with the photodynamic therapy," says Garner, whose practice sees patients from all around the United States for PDT sessions. On top of all that, "You have to consider how much time is taken [to perform the procedure]."
 
Here is a closer look at PDT coding guidelines.

Report Photofrin Administration and Supply

You can report Photofrin injections when the physician gives the shot or when a nurse injects with the physician's supervision. Codes will vary from situation to situation, Pohlig says.
 
"The administration code is selected depending on whether it was infused or injected, on an inpatient or outpatient, with or without a doctor present," she says, "in addition to whether it's a billable visit or not."
 
These are the most commonly used codes for reporting Photofrin administration:
 

When the doctor uses the endoscope to deliver light that activates the tissue-destroying agent in Photofrin, it is possible to bill for an endoscopy. The most frequently used code is 43228 (Esophagoscopy, rigid or flexible; with ablation of tumor[s], polyp[s], or other lesion[s], not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique).
 
The alternative code that you can report is 43258 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with ablation of tumor[s], polyp[s], or other lesion[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique).

Take Advantage of PDT-Specific Codes

In 2000, CPT added codes relevant to the light used during PDT. Use code +96570 (Photodynamic therapy by endoscopic application of light to ablate abnormal tissue via activation of photosensitive drug[s]; first 30 minutes [list separately in addition to code for endoscopy or bronchoscopy procedures of lung and esophagus]) for the first 30 minutes of illumination. For every quarter-hour after that, use code +96571, ... ; each additional 15 minutes [list separately in addition to code for endoscopy or bronchoscopy procedures of lung and esophagus]). 
 
If a patient undergoes 45 minutes of PDT, use 96570 for the first 30 minutes and 96571 x 1 for the final 15
minutes. If the patient had received an hour of treatment, the procedure would be coded as 96570 and 96571 x 2.
 
"Since these are add-on codes, we do not use any modifiers," Garner says.
 
According to Pohlig, many gastroenterology offices are not as thorough as they should be when reporting PDT-specific codes. "If physicians do not include the time associated with light application, they could miss out on the full reimbursement for this service," she says.
 
A few days after the therapy is over, the gastroenterologist performs follow-up to measure the patient's post-PDT progress. An endoscopy also often precedes the PDT in order to determine the exact location of the cancerous cells. Both of these procedures are separately billable, and carriers should reimburse them fully when they are properly reported.