Gastroenterology Coding Alert

Stay calm, and wait for next quarter edits to ameliorate the issue.

Did news of the latest NCCI edits putting the brakes on reporting the new moderate sedation code with one of your EGD codes leave you with a headache? Don’t panic, stay calm and get the inside story to keep accurate reimbursement flowing.

Background: While moderate sedation was an inherent part of over 150 GI procedures until 2016, in 2017 there has been a massive overhaul involving removal of moderate sedation component from over 400 CPT^® codes. This means that you must report moderate sedation separately, whenever your provider documents administration of moderate sedation during a procedure. You now have new CPT^® codes 99151-99153 (Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status…) to report for that service.

The issue: The NCCI PTP edits for the first quarter include an error. Medicare contractor National Government Services recently brought into light the fact that within the NCCI edits, 17 CPT^® codes and 16 category III codes have been incorrectly bundled with the moderate sedation codes 99151-99153. This means that if you submit any of these 33 codes with the new moderate sedation codes, your claim will be denied. “Obviously, there will be no quick turnaround for payment,” says Catherine Brink, BS, CMM, CPC, CMSCS, CPOM, president of Healthcare Resource Management, Inc. Spring Lake, NJ. “I would hold submitting claims until NCCI has been revised. Keep an eye on these edits.”

Think Thrice Before Reporting These Three Gastro Codes for Now

Out of the 33 codes in question, three codes affect your GI coding:

• 43210 (Esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed)
• 45399 (Unlisted procedure, colon)
• 45990 (Anorectal exam, surgical, requiring anesthesia [general, spinal, or epidural], diagnostic)

The catch: This first quarter NCCI edit error ends up not allowing you to bypass the bundling issue with NCCI-associated modifiers, as there is a modifier indicator of “0” displayed alongside these codes in the NCCI PTP table.

The impact: This can have a financial impact on practice depending on how many of these procedures your provider performs, says Brink.

The other affected codes include sleep apnea neurostim­ulator codes (0424T– 0436T), codes for implanted aortic counterpulsation ventricular assist device (0459T – 0461T), procedures on the dialysis circuit (36901 – 36909); transluminal balloon angioplasty (37246 – 37249), and 61640 for balloon dilatation of intracranial vasospasm.

Wait Till April to Submit Codes, Or Face Denials

According to a National Government Services news update, you may expect correction of the errors in the next quarter edits in April. NCCI suggests that you delay the submission of your claims involving the affected services until then. If you submit your claims now, there would be an outright denial, which you may be able to appeal in April once the corrections take effect.

“It is best to avoid getting a denial and accept that these claims will go out up to 60 days late.” says Michael Weinstein, MD, former representative of the AMA’s CPT^® Advisory Panel. “The cost of appealing a denial will not likely be covered by the recouped dollars.”

Expert advice: “Hold claims for these procedures until after April 1, 2017,” says Brink. “Make sure you keep checking the NCCI edits for the corrected revisions before submitting claims. Keep track of these procedures and dates of service so can be submitted at a later date. Plus, advise billers to keep an eye on these codes to make sure they are properly adjudicated and paid.”