Gastroenterology Coding Alert
Latest Version of NCCI Tightens Up Several Gastro Codes
Injections are no longer reportable with some EGD procedures When the gastroenterologist injects saline to raise a polyp before removal, you may have considered reporting two codes in the past. But in the future, you should stick to one code at all times, since the new coding edits officially forbid it. In the latest version of the National Correct Coding Initiative (NCCI) edits, submucosal injections are considered part of many endoscopic procedures. The edits also bundle several codes that represent fine needle aspiration (FNA) and endoscopic ultrasound (EUS) procedures. FNA, EUS Bundles Are Unbreakable The NCCI edits significantly affect several FNA/EUS codes, says Linda Parks, MA, CPC, CMC, CCP, of GI Diagnostic Endoscopy Center in Marietta, Ga. EGD With EUS Is a 1-Code Claim From now on, when you report an EUS with an endoscopy, 43237 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with endoscopic ultrasound examination limited to the esophagus) is bundled into 43231 (Esophagoscopy, rigid or flexible; with endoscopic ultrasound examination). Example: Let's say the gastroenterologist performs an EGD with an endoscopic ultrasound limited to the esophagus. NCCI now requires you to report only 43237 for this procedure. Beware of Reporting FNA With Endoscopy With the new edits, when you report an FNA with an endoscopy, 43238 (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], esophagus [includes endoscopic ultrasound examination limited to the esophagus]) is bundled into code 43237. Example: The gastroen-terologist is conducting an EGD, during which he performs an EUS and an FNA in the same area. You should report only 43238. More Injection Bundles NCCI has also made the following changes to other FNA/EUS codes:
You Can Undo Injection Edits -- Sometimes The new edits will also affect reporting endoscopic procedures in which the gastroenterologist performs a submucosal injection, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the CPT advisory panel. "The majority of the new edits are related to newer CPT codes from 2003 and 2004," Weinstein says. Of those edits, gastro coders should focus on a quartet of injection codes that "are listed in multiple permutations in keeping with prior edits on other endoscopic codes," he says. The injection codes Weinstein is referring to are: The next time your gastroenterologist performs an endoscopic procedure with submucosal injection and an endoscopic procedure at the same site, check with NCCI before reporting the injection separately. Example: In the middle of a sigmoidoscopy, the gastroenterologist discovers a polyp. He injects the polyp with saline to raise it, then removes it via snare technique. Why? NCCI now considers the injection to be part of the work involved in the polyp removal, so coding for both the injection and the removal would be "double-dipping." Exception: All of the above injection codes have "1" indicators, meaning they could be separately reportable in certain circumstances, Weinstein says. One of the acceptable circumstances for unbundling a "1" edit is if the gastroenterologist performs procedures at separate sites, says Kimberly Green, CPC, project coordinator at the University of Pittsburgh Physicians. Example: The gastroenterologist performs a colonoscopy, and in the cecum he finds a polyp, which he removes by snare technique. While investigating the transverse colon, the gastroenterologist sees a suspicious area that he injects with India ink. The NCCI allows you to unbundled the edits in this case. Why? The modifier lets the carrier know that although the two procedures share the same base code, the polyp removal and India-ink injection were separate procedures in separate areas. Payoff: The relative value units (RVUs) for 45385 are 7.72 for facilities and 13.33 for nonfacilities, while the RVUs for 45381 are 6.13 for facilities and 12.58 for nonfacilities. Read Them for Yourself Visit the NCCI edits on the World Wide Web at http://cms.hhs.gov/physicians/cciedits/default.asp. The edits are in spreadsheet form, allowing users to sort by procedural code or effective date.
Read on for more information on the latest round of NCCI edits, which were the rule as of July 1 and will remain in effect until Sept. 30.
All of the following edits have an indicator of "0," meaning they cannot be unbundled for any reason. "Still, I don't see these edits being a major problem [for coders], since you should always code to the highest degree of specificity to begin with," Parks says.
When reporting the session, you should report only 45338 (Sigmoidoscopy, flexible; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique). The injection code 45335 is not separately reportable in this scenario.
When filing this claim, you should:
If you undo an NCCI edit, make sure you include documentation that proves the procedures were performed at different sites.
Also, make sure you remember to attach modifier -59 to the lesser-valued procedure so you receive the maximum possible reimbursement.
The new Web page also includes links to documents that explain the edits, the NCCI Policy Manual for Part B Medicare Carriers, the Medicare Carriers Manual, and the NCCI Question and Answer page.
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