Gastroenterology Coding Alert

Although the latest Correct Coding Initiative (CCI) version 8.3 adds several infusions to the list of bundled procedures, the edits, which are effective Oct. 1, 2002, leave most gastroenterology practices untouched.

The trend in current CCI edits, especially for surgical procedures, is that injection services are being bundled into the more extensive procedures with which they are performed. This is an obvious attempt by CMS to increase the standard of care. They reason that when a lesser-valued procedure is always performed with a more extensive procedure, it becomes an integral part of the higher-valued procedure and therefore should not be billed separately.

The most extensive edit involves code 90780 (Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour). 90780 is used to report the first hour of IV infusion, while 90781 is an add-on code for each additional hour. The edit bundles the infusion into most gastroen-terological procedures (40490-49906). This means that the component procedure, or infusion, will not be reimbursed when it is rendered by the same physician on the same date of service. It is now part of the comprehensive procedure.

This may seem hard on doctors, but many coders urge that this will not greatly affect gastroenterologists. "It won't affect my coding at all, because we don't use that code in conjunction with our gastro procedures," says Margaret Lamb, RHIT, CPC, Great Falls Clinic, Great Falls, Mont. Rarely during their regular GI procedures (scopes) has she coded for an intravenous infusion related to the scope. IVs are mainly used for sedation.

Lamb holds that her clinic usually only uses the intravenous infusion with "unrelated procedures." Lamb notes only one instance of billing an intravenous code when the doctor did an infusion of albumin following a therapeutic paracentesis (49080). She agrees with the CCI edits that "if you are doing a concurrent infusion, it should be part of the procedure performed and not reimbursed separately."

Another way that this edit may affect you is in the treatment of Crohn's disease. Lois Curtis, CPC, billing manager, Gastroenterology Associates, Evansville, Ind., says she has only heard of code 90780 being used for Remicade infusions for Crohn's patients. Remicade is often used in the treatment of moderate to severe Crohn's patients who do not respond to standard treatments. Most insurance plans cover this treatment but now will not pay for it when billed separately.

Fortunately, the edits indicate that coders can override the new gastroenterology bundles by using a modifier. Lamb says that "the only way around the new CCI edit is if it truly is being done separately from the GI procedure performed." For example, if an infusion does get bundled into the paracentesis code (49080), then you can use modifier -59 (Distinct procedural service) to unbundle it because it is a separate, distinct procedure that is being performed.

The CCI edits encompass a wide array of bundled injection procedures that could interfere with your billing. These injection codes apply to most of the comprehensive procedures that gastroenterologists provide.

36000* Introduction of needle or intracatheter, vein

36410* Venipuncture, child over age 3 years or adult, necessitating physician's skill (separate procedure), for diagnostic or therapeutic purposes. Not to be used for routine venipuncture

37202 Transcatheter therapy, infusion other than for thrombolysis, any type.

Once again, you can use a modifier to override the bundles. Strictly apply modifier -59 rules to unbundle these infusions from their related procedures.

The CCI edits grace us with some mutually exclusive coding pairs. CCI guidelines explain that mutually exclusive codes are "those which cannot be performed during the same operative session." In this case, the second procedure will not be reimbursed when it is rendered by the same provider on the same day of service.

Gastroenterologists should note that the laparoscopy codes (47370-47371) cannot be billed together or with the codes for excision or destruction of tumors or cysts in the abdomen (49200-49201).

Three other procedures 47380 (Ablation, open, of one or more liver tumor[s]; radiofrequency), 47381 ( cryosurgical), and 47382 (Ablation, one or more liver tumor[s], percutaneous, radiofrequency) are affected by this change. 47380 should not be reported with 47381, and 47382 should not be reported with 49200 (Excision or destruction by any method of intra-abdominal or retroperitoneal tumors or cysts or endometriomas) or 49201 ( extensive). Once again, this follows with normal coding convention that the lesser procedure is bundled into the more extensive procedure. These edits are consistent with these guidelines.

Here, also, the edits allow for modifiers to be applied in certain circumstances.