Gastroenterology Coding Alert

The latest version of the Correct Coding Initiative (CCI), which went into effect July 1, contains edits for the new gastroenterology codes that were introduced in CPT 2001. CCI 7.2 creates edits for the following new gastroenterology codes:
 

43231 -- esophagoscopy, rigid or flexible; with endoscopic ultrasound examination
 

43232 -- ...  with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s)
 

43240 -- upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transmural drainage of pseudocyst
 

43242 -- ... with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s)
 

43256 -- ... with transendoscopic stent placement (includes predilation)
 

44370 -- small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with transendoscopic stent placement (includes predilation)
 

44379 -- small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with transendoscopic stent placement (includes predilation)
 

44383 -- ileoscopy, through stoma; with transendoscopic stent placement (includes predilation)
 

45341 -- sigmoidoscopy, flexible; with endoscopic ultrasound examination
 

45342 -- ... with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s)
 

45345 -- ... with transendoscopic stent placement (includes predilation)
 

45387 -- colonoscopy, flexible, proximal to splenic flexure; with transendoscopic stent placement (includes predilation)

 
The CCI is a set of published edits or computer instructions that help Medicare payers identify improper medical claims. The CCI edits, which are published quarterly, are designed to give payers and providers more direction on how to bill certain coding combinations.
 
Each version of the CCI contains two lists of edits. The list of mutually exclusive edits contains coding combinations that cannot reasonably be done in the same session. The list of comprehensive/component edits contains procedures that Medicare considers to be components of a more comprehensive procedure. In other words, the component codes are "bundled" into the comprehensive code and are not separately reportable unless the component procedure is separate and distinct.
 
When a coding combination is listed as either a mutually exclusive or comprehensive/component edit, the general rule is that both codes cannot be reported separately. However, the CCI also contains superscripts (also known as Correct Coding Modifiers [CCM]) to indicate coding combinations that can be reported separately under appropriate circumstances. A CCM of 0 indicates that it is never acceptable to bill these procedures together. A CCM of 1 indicates that those codes are considered bundled but can be billed separately under certain circumstances. In gastroenterology, modifier -59 (distinct procedural service) is the primary modifier used to override CCI edits with an indicator of 1.
 
For gastroenterology practices, most of the significant CCI additions in version 7.2 are in the comprehensive/ component list. While all the new codes received edits, none of them should be surprising. For example, codes 43200 (esophagoscopy), 44360 (small intestinal endoscopy, not including ileum) and 44376 (small intestinal endoscopy, including ileum) are now listed as component codes to comprehensive codes 43231 and 43232. Each pair of the edits has a 0 subscript, which means that under no circumstances can these codes be billed together.
 
Codes for helicobacter pylori (H. pylori) tests, many of which were revised in CPT 2001, also received edits.

The following helicobacter pylori test codes were affected:
 

78267 -- urea breath test, C-14; acquisition for analysis
 

78268 -- urea breath test, C-14; analysis
 

83013 -- H. pylori; analysis for urease activity (mass spectrometry)
 

83014 -- H. pylori; drug administration and sample collection
 

87338 -- H. pylori, stool

 
The edits for these tests are straightforward and prohibit gastroenterologists from reporting two variations of the test on the same day. CCI 7.2, for example, bundles 78267 and 83014, which means gastroenterologists cannot bill for administering both a C-13 and C-14 version of the H. pylori breath test on the same day.
 
For more information on interpreting the CCI, please see "Use of CCI Edits to Determine When to Use Modifier -59," on page 33 of the May 2001 Gastroenterology Coding Alert. To view your subscription online, visit www.codinginstitute.com or call our friendly customer service department at 1-800-508-2582. The latest version of the CCI can be ordered from the National Technical Information Service (NTIS) by calling 1-800-363-2068 or by going online at www.ntis.gov/product/correct-coding.htm.