Gastroenterology Coding Alert

Modifier -22, Related Codes Can Be Used to Increase Reimbursement for Balloon Dilations

Although balloon dilation of the lower intestine is commonly performed by gastroenterologists, CPT does not include specific codes for performing the procedure in every part of the lower intestine. But coders can use related codes or modifier -22 (unusual procedural service) when determining how to bill for this procedure to increase their reimbursement opportunities.

Balloon dilation is used for enlarging strictures and clearing fibrous scar tissue or tumors blocking the gastrointestinal tract, explains Glenn D. Littenberg, MD, FACP, a gastroenterologist in Pasadena, CA, and a member of the American Medical Associations (AMA) CPT editorial panel. The dilator is inserted under endoscopic or fluoroscopic guidance and then a balloon catheter is inflated at the site of the stricture. Other methods of dilation include the use of a bougie, plastic stent, Savary dilation and retrograde dilation.

Use Modifier -22 or Unlisted Codes for Colon

CPT does provide codes for reporting balloon dilation in a few areas of the lower intestine. Code 45303 (proctosigmoidoscopy with dilation, any method) can be used for balloon dilation of the rectum and sigmoid colon. Code 46604 (anoscopy with dilation, any method) can be used for the anus.

There are, however, no equivalent codes for performing a balloon dilation in conjunction with a flexible sigmoidoscopy, colonoscopy or an endoscopy of the small intestine. Although these procedures are not uncommon, they were developed more recently than the techniques for the upper gastrointestinal examination, and CPT has not created codes for them yet, says Littenberg.

There are two options for coding these unlisted balloon dilation procedures, according to Pat Stout, CMT, CPC, an independent gastroenterology coding consultant. The first is to use the base endoscopy code in the relevant family with modifier -22.

For a balloon dilation of the colon, for example, the code 45378 (colonoscopy) would be used with modifier -22 attached to it.

Another way to code for this situation would be to use the unlisted procedure code for the intestine, 44799 (unlisted procedure, intestine) in addition to the base endoscopy code. In the case of a balloon dilation of the colon, the code 45378 would be listed first, followed by the unlisted procedure code 44799.

Adequate documentation must accompany the claim regardless of how its coded, advises Littenberg, and should include the operative report and a separate statement describing the steps taken in the balloon dilation procedure. This separate report should include the typical time taken to complete the procedure and mention a listed service that is its closest equivalent.

Streamlining the Appeals Process

Gastroenterologists likely will not be reimbursed the first time they bill a local payer for an unlisted balloon dilation, according to Stout. She adds that many gastroenterologists end up performing the procedure for no extra charge rather than go through the hassle of filing an appeal. They really shouldnt be doing this for free, however, she emphasizes.

Littenberg also acknowledges that filing an appeal to receive reimbursement for this type of claim requires a lot of effort. He recommends contacting the insurance carrier to learn which coding method will be reimbursed, keeping that information on hand, and following the same procedure each time a claim for balloon dilation is submitted.

Upper G.I. Dilation Codes Explained

There are several CPT codes for balloon dilation of the upper gastrointestinal tract, many of which Littenberg feels often are confusing to gastroenterologists. Some physicians might use one of the upper gastrointestinal dialtion codes when he or she actually performed the dilation in the lower part of the tract, not knowing that there may be a specific code for that treatment.

For example, code 43249 (upper gastrointestinal endoscopy with balloon dilation of esophagus less than
30 mm diameter
) should be used only when balloon dilation is done as part of a complete upper gastrointestinal endoscopy that includes the esophagus, stomach and either the duodenum and/or the jejunum. Code 43220 (esophagoscopy, rigid or flexible with balloon dilation of less than 30 mm diameter), on the other hand, should be used when the dilation is part of an esophagoscopy that does not go to the stomach, duodenum or jejunum.

When a gastroenterologist performs a balloon dilation for the first time on a patient as part of a complete upper gastrointestinal exam, it should be billed as 43249, explains Littenberg. If the patient returns for dilation only, it would be coded 43220.

Balloon dilation also is used for treating achalasia (530.0), which is not a stricture but a muscle disease of the esophagus, notes Littenberg. In that case, an extra large balloon is used for the dilation, and 43458 (dilation of esophagus with balloon [30 mm diameter or larger] for achalasia) should be used.