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Gastroenterology Coding Alert

Make Sure the Newest NCCI Edits Don't Upset Your Clean Claims

Published on Thu Oct 23, 2003

Do you bill twice when replacing a PEG tube? If so, you should take a close look at the latest National Correct Coding Initiative (NCCI) edits; it could change the way you think.
 
The NCCI version 9.3 edits took effect Oct. 1 and will be the rule until Dec. 31, so all relevant changes need to be noted to avoid red tape. Gastroenterology offices will be most affected by four new NCCI bundles. Here is a look at these new bundles and what you need to look for to eliminate improper filings and maximize payment in light of the new edits.

NCCI Brings Biopsy Bundles to Esophagoscopy

 The procedures NCCI has bundled into 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple) will likely shock no one. When an esophagoscopy is performed, all stomach or intestinal biopsies conducted during it should be bundled into 43239. This edit removes all doubt about billing 43600 (Biopsy of stomach; by capsule, tube, peroral [one or more specimens]) or 44100 (Biopsy of intestine by capsule, tube, peroral [one or more specimens]) in addition to the endoscopy (or esophagogastroduodenoscopy).
 
"These are not surprising, and I can't imagine that anyone would bill both codes - except to game the system," says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the CPT advisory panel. Although these edits all have an indicator of "1"  - meaning that the procedures can be separately reported for a single patient encounter that meets certain criteria - Weinstein doesn't think they would apply in most situations.

Fluoroscopy Is Now Part of ERCP

When you report a standard endoscopic retrograde cholangiopancreatography (ERCP), the procedural codes (43260-43272) now include fluoroscopy, regardless of the time or resources expended. The edit nullifies the possibility of reporting the ERCP and then separately coding the fluoroscopy with either of the following:

  • 76000 - Fluoroscopy (separate procedure), up to one hour physician time, other than 71023 or 71034 (e.g., cardiac fluoroscopy)

  • 76001 - Fluoroscopy, physician time more than one hour, assisting a non-radiologic physician (e.g., nephrostolithotomy, ERCP, bronchoscopy, transbronchial biopsy).

    This edit is new for the NCCI, but the revision probably won't be revelatory to most coders, says Linda Parks, MA, CPC, CMC, CCP, of GI Diagnostics Endoscopy Center in Marietta, Ga.

    "The spring 1994 CPT Assistant and the June 2000 GI Coding Alert had already reported that these codes were not to be billed together," Parks says. "The use of contrast material and the fluoroscopy are standard components of ERCPs."

    No More Double-Billing for PEG-Tube Replacement

    In the world of PEG procedures, the NCCI has closed a loophole that may have allowed double-billing when a PEG tube was endoscopically replaced.
     
    You should report 43246 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube) only once when an old PEG tube is removed and a new one is inserted. Previously, offices could have billed for a double procedure: 43246 for the new PEG-tube placement and 43247 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of foreign body) for removal of the old tube.
     
    While you can no longer report 43246 and 43247 for standard PEG-tube replacements, these edits have a "1" indicator, which means you can use a modifier to separately report the two in certain situations. For example, if a doctor has to remove an unanticipated foreign body from the esophagus during the PEG-tube replacement, 43246 and 43247 are allowably coded separately with modifier -59 (Distinct procedural service) attached.

    NCCI Blitzes 'Foreign Body' Code

    Code 43247 (... with removal of foreign body) was roundly affected by the latest edits. Not only was it bundled into 43246 for certain procedures but it also had three codes bundled into it.
     
    From now on, 43247 will include 43760* (Change of gastrostomy tube). According to Weinstein, the edit solidifies 43247 as the correct code for PEG-tube removal.
     
    The NCCI also bundled 43450* (Dilation of esophagus, by unguided sound or bougie, single or multiple passes) and 43453 (Dilation of esophagus, over guide wire) into 43247.
     
    The NCCI edits are posted at http://cms.hhs.gov/physicians/cciedits/default.asp. The edits are posted as a spreadsheet, allowing users to sort by procedural code or effective date. The new Web page also includes links to documents that explain the edits, the NCCI Policy Manual for Part B Medicare Carriers, Medicare Carriers Manual, and the NCCI Question and Answer page.

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