Gastroenterology Coding Alert

If coding for the new GERD treatments leaves you dazed and confused, you need to freshen up on the latest guidelines for reporting Stretta, ELGP, and fundoplication.

In the past, coders have been confused about whether to report combination or unlisted-procedure codes for Stretta and whether even to bill for the newer endoluminal gastroplication procedure. You can breathe a sigh of relief because guidelines do exist that will help lead you down the road to better reimbursement for your treatment options for GERD (gstroesophageal reflux disease).

One of the most common GERD treatment problems deals with the Stretta technique. Gastroenterologists perform this procedure endoscopically, and it involves inserting a series of electrodes into the lowest part of the esophagus, says Teresa Baker, CPC, physician billing manager for the Gastroenterology Division at the University of Michigan. These electrodes deliver radiofrequency energy to create thermal lesions that make a barrier to prevent the reflux of gastric contents into the esophagus.

If you're receiving denials for your Stretta procedures, you may be using the wrong CPT combination codes. In the past, gastrointestinal coders heard that CMS approved the coding combination of 43258 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with ablation of tumor[s], polyp[s], or other lesion[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique) and 64640 (Destruction by neurolytic agent; other peripheral nerve or branch).

CMS discourages this method of coding. CPT explicitly states that you should not "select a CPT code that merely approximates the services provided." According to Pat Stout, CMC, CPC, an independent gastroenterology coding consultant in Knoxville, Tenn., current CMS guidelines tell you to code 43499 (Unlisted procedure, esophagus). If the endoscopy includes another procedure, such as a biopsy or dilation, you should bill the appropriate code, such as EGD with biopsy (43239). In general, you should report the appropriate unlisted-procedure or service code when no code exists that properly describes the procedure performed.

The problem with Stretta is that you have to use unlisted-procedure codes, which lead to unstable reimbursement. Stout urges coders to ask their major payers in the area for their guidelines for billing Stretta, rules on precertifi-cation, and the difficulty of receiving payment. Payment varies, and most of the time with unlisted-procedure codes, you have to appeal to receive any reimbursement, she says. Several carriers will not even cover the procedure.

You should hold off on rushing to report UPcodes for emerging technologies until you check in the back of your CPT book for a category III codes that corresponds to your procedure. Endoluminal gastroplication (ELGP) is an emerging technology that does have a category III code, 0008T (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with suturing of the esopha-gogastric junction).

ELGP, otherwise known as endoscopic fundoplication, involves the use of the Bard EndoCinch to reduce the size of the opening from the stomach into the esophagus, rendering the lower sphincter more functional. Many practices are used to billing 43499, but this is not the most specific coding practice, since the category III code exists.

You may face certain challenges when it comes to billing for these relatively new procedures. Many practices worry that carriers view the category III codes as experimental and refuse reimbursement. According to Blue Cross Blue Shield of Alabama, they will consider procedures performed using the Bard Endoscopic Suturing System or EndoCinch System investigational and non-covered because there are only limited long-term studies and data to prove the efficacy of this form of gastroplication.

Another problem arises because Medicare has not assigned category III and UP codes their own relative value units (RVU). Therefore, carriers must manually review these claims. Gastroenterologists must determine a value for the service, usually by comparing it to a similar service. Yet, there is no guarantee that you will receive reimbursement.

As with the Stretta procedure, Stout says that you may face problems with ELGP because it is an emerging technology. Once again, ask your payers for their guidelines for billing and whether they are reimbursing for the procedure. You should be able to receive payment, though it depends on the carrier.

The more invasive technique used to treat GERD involves laparoscopic or open surgery, commonly called Nissen fundoplication. This procedure involves lengthening the esophagus and building a barrier around the stomach so that the reflux does not come straight up, Baker says.

Gastroenterologists refer most of these cases to general surgeons, who perform the surgery. Coding depends on the procedure used: 43280 (Laparoscopy, surgical, esophagogastric fundoplasty [e.g., Nissen, Toupet procedures]) or 43324 (Esophagogastric fundoplasty [e.g., Nissen, Belsey IV, Hill procedures]).

Although gastroenterologists do not normally perform Nissen procedures, you may face some difficult issues when it comes to postoperative care. According to Stout, physicians sometimes have to perform endoscopies on patients who have undergone Nissen fundoplication. Due to anatomic changes from the surgery, the physician cannot insert the scope to the full definition of the code. For example, a gastroenterologist starts to perform an EGD on a Nissen patient. Because of anatomic changes, the physician cannot perform the full endoscopy. When this is the case, you should use 43200 (Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) rather than 43235-52 (Upper gastrointestinal endoscopy ...) for a reduced service.