Part II:
Sift Through the Maze of GERD Treatment Options
Published on Tue Apr 01, 2003
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). Throw Out Combination Codes for Stretta 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. ELGP Requires Category III Code 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 [...]
