Gastroenterology Coding Alert

Although Given Imaging's M2A Video Capsule System is the hot new technology for diagnosing gastrointestinal disorders, gastroenterologists who perform the procedure must be prepared to go through the hassle and uncertainty that comes with reporting a new technology to insurers. There are a variety of codes used to report the M2A capsule, and gastroenterologists will probably have to precertify the procedure and file manual claims in order to provide extra information to payers.
 
"As with most new procedures, the initial gastroenterologists who use the M2A capsule will have to deal with claims that require extra work and may not always be compensated properly for it," says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the CPT advisory panel. "It will take one or two years before carriers and payers get everything worked out. Doctors don't like to wait that long, but they'll have to get used to that fact."

The M2A capsule is a noninvasive technique for visualizing the entire small bowel including the distal ileum, which is difficult to observe with standard endoscopes, says Cheryl Soderholm, director of reimbursement at Given Imaging. The capsule was approved for use by the Food and Drug Administration on Aug. 1, 2001, and is intended for the visualization of small bowel mucosa as an adjunctive tool in the detection of abnormalities of the small bowel.
 
The M2A system requires three components:
 
1. the M2A capsule endoscope, a disposable, swallowable capsule that captures video images as it is naturally propelled through the digestive system
 
2. an external data recorder and sensor array that receive data transmitted
by the capsule
 
3. a modified standard computer that acts as a workstation for the storage, interpretation and analysis of the acquired images and for generating reports.

During the procedure, the array of sensors is placed on the patient, who is also fitted with a belt to hold the external recorder. After the patient is given the capsule to swallow, he or she can resume a regular schedule of activities while the capsule travels through the digestive tract during the next seven to eight hours. The capsule is eventually excreted naturally. The video images in the recorder are then downloaded to the workstation. Once the download is complete, the gastroenterologist has approximately 50,000 images to review and interpret. Depending on the complexity of the patient's condition and the gastroenterologist's level of experience, the review could take from 30 minutes to two hours.
 
As they become more comfortable with the procedure, gastroenterologists may have a staff member assist with tasks such as the placement of the sensors, Soderholm reports. In addition, a staff member is usually responsible for downloading the data from the recorder to the workstation, a process that can take more than two hours.
 
Because it is a new technology, CPT has yet to develop a specific code to cover the procedure and most payers have not established medical policies regarding reimbursement and covered conditions. "You could probably use two or three different unlisted codes for the M2A capsule an endoscopy code or gastrointestinal diagnostic code," says Weinstein, who recently began performing the M2A procedure. "Some people have even suggested a radiological code."
 
The carriers and payers that reimburse for the M2A procedure seem to require one of three coding options.

One option is to use endoscopy code 44376 (small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]). The argument for using this code is that many feel it best describes the results produced by the M2A capsule, which is a visualization of the small bowel.
 
Code 44376 was originally used to report Sonde enteroscopy, which many feel is similar to the M2A procedure. In the Sonde procedure, an endoscope is introduced to the patient through the nose or mouth and is advanced by peristalsis to the distal ileum, a process that requires the patient to be in a lateral position for around eight hours. When the endoscope reaches the distal ileum, the gastroenterologist reviews the video images. Total involvement by the gastroenterologist is usually around one-and-a-half hours. Due to the discomfort to the patient, Sonde enteroscopy is rarely performed.
 
Another factor in favor of 44376 is that it is the only code of the three options that has an established Medicare relative value unit (RVU) a hefty 7.91 for 2002.
 
"Many gastroenterologists feel that the description is appropriate," Soderholm says. "When you look at the amount of time that this requires, some would argue that the payment under even this code is low and does not allow them to recoup."
 
The problem with this code is that many feel that the M2A procedure is not the type of endoscopy described by 44376. "In my opinion, M2A is not a standard endoscopy because you are not sedating the patient or passing a mechanical tool down his or her throat to the gullet. The procedure does not require a gastroenterologist to be present during the actual image capturing," Weinstein says. "Unless there is an explanation of the difference between Sonde enteroscopy and the M2A capsule on the claim, this is not an appropriate code to use."
 
He also disagrees with the argument that the code is appropriate because it describes the same results that the M2A capsule produces. "The CPT codes are based on the physician's work, overhead and intensity of the procedure," he explains. "It is not based upon results or outcomes. It is not based on what these pictures look like."
 
A revised statement from the American Medical Association CPT advisory board, which appears at the beginning of CPT 2002, also seems to support Weinstein's opinion. The statement directs physicians to "select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided. If no such procedure or service exists, then report the service using the appropriate unlisted procedure or service code." (Revisions are in italic.)
 
Whether 44376 is the best code to use, many gastroenterology coders report that their Medicare carriers and private payers are requiring that they use this code to report the M2A procedure. Weinstein and Soderholm agree that if 44376 is reported, the gastroenterologist must indicate on the claim that the capsule was used instead of an endoscope. To do this, the practice must file a manual claim instead of an electronic one and attach a procedure report with cover letter. "If gastroenterologists choose this option, we suggest that they indicate to the payer that the procedure was performed with an M2A capsule in box 19 of the claim form," Soderholm explains. "Always be up-front with the payers and explain that this is a different type of endoscope."
 
Weinstein also recommends attaching modifier -22 (unusual procedural services) to the code to indicate that the procedure is different than the standard flexible scope enteroscopy.

Option 2: Unlisted-Procedure Code 44799
 
 
Another option is to report the procedure using 44799 (unlisted procedure, intestine). Filing with an unlisted code is more time consuming, however, because the claim must include an operative report and a separate statement describing the steps taken during the procedure.
 
A bigger drawback to using this unlisted code comes when the gastroenterologist must cite a related procedure as the basis for the fee he or she wants to charge, and a similar endoscopy procedure doesn't exist. "The question with unlisted codes is how do you figure how much to charge," Soderholm says. "For any procedure that is unlisted, you have to look back in the practice and find another procedure that closely resembles this particular procedure."

The third option is to use unlisted code 91299 (unlisted diagnostic gastroenterology procedure). This code is in the section of CPT that includes other gastrointestinal diagnostic tests such as esophageal motility studies (91010), esophageal manometry (91020) and pH monitoring (91032-91033).
 
There is no question that the M2A procedure is similar in intent and execution to these other diagnostic studies and that gastroenterologists could easily cite a diagnostic test such as pH monitoring as the related code to serve as the basis for the fee that he or she wants to charge. The drawback is these diagnostic tests have a low level of reimbursement. The RVU for the pH monitoring global code 91033 is only 4.08 not much given the substantial amount of time that the gastroenterologist may spend on the M2A procedure.
 
Although this is the code that his practice now uses to report the M2A procedure, Weinstein acknowledges that there may be some problems in comparing it to other diagnostic tests. "The M2A capsule takes a lot more time than 24-hour pH monitoring," he says. "That probably takes about 10 minutes of physician time to review. The M2A takes 30 to 40 minutes, plus similar set-up time of 30 to 40 minutes."
 
To extract a more equitable reimbursement, Weinstein's practice notes the extra time the M2A procedure takes in the claim. "For a work comparison, we cite the 24-hour pH monitoring code with a clear notation that the M2A requires a significantly increased amount of physician time to review the images," he explains. A number of gastroenterologists who have used this unlisted code have reported that they have suggested fees of $300 to $600 for the M2A procedure.

Bill for Capsule

The M2A capsule should also be reported with unlisted supply code 99070 (supplies and materials [except spectacles], provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]). "Disposable endoscopic device integral to the procedure" should be written next to the code, Soderholm says. A copy of the receipt for the capsule should be attached to the claim.
 
Pass-through supply codes for the outpatient and hospital setting have been applied for and should be approved in the next several months, Soderholm says.

Discussing the procedure and reimbursement issues with the payer in advance can ease reimbursement hassles for the M2A capsule. "Prior authorization with the payer should be done on a case-by-case basis to determine the medical needs of the patient and to provide information on the procedure," Soderholm says. "Right now there is a need for proper presentation to the payer on what the gastroenterologist is doing and why. Also, if you preauthorize with a payer, it will know upfront what the procedure is and that it is performed with an M2A capsule, not a standard endoscope."
 
Weinstein also recommends precertifying the procedure with the insurer when possible and getting the patient to sign a waiver acknowledging financial responsibility when it isn't. "We try to contact the insurance company ahead of time because these cases aren't usually urgent, and you have time to try to get the procedure preauthorized," he says. "If we can't, then we have the patient sign a waiver and he or she is responsible for the supplies and service."