Gastroenterology Coding Alert

Maloney dilations are no longer separately reportable in some scenarios

If you've been reporting separate dilation CPT Codes in conjunction with certain types of EGDs, you may want to check the most recent edition of the National Correct Coding Initiative (NCCI) before doing it again. The NCCI's newest edits, effective as of April 1, now forbid it in even more situations.

1-Code Claims Only for Balloon Dilation EGDs

Code 43249 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with balloon dilation of esophagus [less than 30 mm diameter]) was amended to include Maloney (also known as "unguided sound or bougie") manipulation and guidewire manipulation.

Effect: The codes for those types of manipulations --  43450 (Dilation of esophagus, by unguided sound or bougie, single or multiple passes) and 43453 (Dilation of esophagus, over guidewire) -- can never be reported separately with 43249, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the CPT advisory panel. Weinstein reports that this new edit does not appear to be consistent with other edits and with clinical practice. A request to change the edit to allow use of 43450 with 43249 is being considered. 

Previously, CPT permitted billing 43248 (... with insertion of guidewire followed by dilation of esophagus over guidewire) and either 43450 or 43453 with modifier  -59 (Distinct procedural service) appended. If an unusual procedure report includes documentation for both balloon and guidewire dilation, the claim should show both 43248 and 43249. 

Payout: The higher-valued code, 43248, will be paid fully, and the lesser code, 43249, will be paid minus the base endoscopy code (43235). For now, Medicare processing will not allow 43249 with 43450, but other commercial carriers may process the claims differently.

This may not affect all offices equally, says Linda Lauer, billing supervisor at Gastroenterology and Hepatology Associates in Allentown, Penn. She says she used 43248 only a handful of times in 2003, but all of those claims could have been denied if Lauer hadn't known the proper bundles.

EGD With Guidewire Gets Lesser Bundle

The other notable NCCI edit isn't far from 43249 in the CPT book. CPT also amended 43248 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with insertion of guidewire followed by dilation of esophagus over guidewire), though not as significantly as 43249.

Effect: From now on, when reporting 43248, you cannot report the manipulation code 43453 separately. If you were (or are) reporting 43248 and 43453 with modifier -59, you should stop immediately.

Exception: Unlike 43249, the NCCI did not bundle Maloney dilation into 43248. If your gastroenterologist performs an EGD with guidewire dilation, continue to report 43248 and 43450 with modifier -59 attached if a Maloney bougie is used to dilate a separate site usually at the upper esophageal sphincter, Weinstein says.

"It is still appropriate to use both 43248 and 43249 if both of these techniques are used to dilate the esophagus," Weinstein says.

Editor's note: 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, the Medicare Carriers Manual, and the NCCI Question and Answer page.