Gastroenterology Coding Alert

Learn the new infusion and hydration codes or face denials on Jan. 1.

Do you ever struggle to get an unlisted procedure code paid? CPT 2009 has the cure for one procedure your gastroenterologist may have been doing if she invested in the latest endoscopy equipment.

CPT provides new codes for when your gastroenterologist views inside the bile duct with a camera. It also changes codes for when your physician destroys hemorrhoids with thermal energy. Here's what you need to know about the new year's

new codes.

The latest technology has made it possible for your physician to actually see inside the ducts that carry bile to the small intestine, but until now there hasn't been a code for using the tiny camera that she'd use. A new code could prove useful for

some practices, says Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta.

CPT 2009 catches up with that tiny camera with an add-on code for endoscopic retrograde cholangiopancreatography (ERCP) procedures, +43273 (Endoscopic cannulation of papilla with direct visualization of common bile duct[s] and/or

pancreatic duct[s] [List separately in addition to code(s) for primary procedure]).

To use this code, your physician will need to perform ERCP, which includes codes 43260, 43261, 43263-43265, and 43267-43272 (Endoscopic retrograde cholangiopancreatography [ERCP] ...).

You'll be looking for evidence in the doctor's notes that she cannulated, entered, or penetrated the papilla of Vater, which is where the bile duct empties into the lower intestine, or that she viewed the common bile duct or pancreatic duct.

You'll have fewer hemorrhoid-destruction codes to rely on with CPT 2009. The AMA deletes 46934-46936 (Destruction of hemorrhoids, any method ...) and adds one new code, 46930 (Destruction of internal hemorrhoid[s] by thermal energy [e.g.,

infrared coagulation, cautery, radiofrequency]).

A note appended to 46930 announces the demise of the old hemorrhoid destruction codes and refers you to several other codes: "For incision of external thrombosed hemorrhoid(s), use 46083; for destruction of internal hemorrhoids by thermal

energy, use 46930; for destruction of hemorrhoid(s) by cryosurgery, use 46999; for excision of hemorrhoid(s), see 46250-46262, 46230; for injection, use 46500; for ligation, see 46221, 46945, 46946; for hemorrhoidopexy, use 46947."

CPT 2009 appends a lot of notes to various gastroenterology codes. Here's a roundup:

• 43752 --" Naso- or oro-gastric tube placement, requiring physician's skill and fluoroscopic guidance (includes fluoroscopy, image documentation and report)

"(Do not report 43752 in conjunction with critical care codes 99291-99292, neonatal critical care codes 99468, 99469, pediatric critical care codes 99471, 99472, or low birth weight intensive care service codes 99478, 99479)"

The above note reflects significant changes in E/M codes for critical, neonatal and pediatric codes.

• 43882 --" Revision or removal of gastric neurostimulator electrodes, antrum, open

"(For electronic analysis and programming of gastric neurostimulator pulse generator, see 95980-95982)"

• 45170 --" Excision of rectal tumor, transanal approach 

"(For transanal endoscopic microsurgical [i.e., TEMS] excision of rectal tumor, use 0184T)"

The last two notes reflect the changes in hemorrhoid-destruction codes:

• 46262 --" Hemorrhoidectomy, internal and external, complex or extensive; with fistulectomy, with or without fissurectomy

"(For injection of hemorrhoids, use 46500; for destruction, use 46930; for ligation, see 46945, 46946; for hemorrhoidopexy, use 46947)"

• 46500 --" Injection of sclerosing solution, hemorrhoids

"(For excision of hemorrhoids, see 46250-46262; for destruction, use 46930; for ligation, see 46945, 46946; for hemorrhoidopexy, use 46947)"

Get ready for a whole new way to code hydration services starting in January.

Just as you were getting to know codes 90769-90771 (Subcutaneous infusion for therapy or prophylaxis...) -- which CPT debuted in January, 2008 -- it's time again to forget what you learned and start coding a new way.

Gone, but not lost: CPT 2009 deletes the entire "Therapeutic, Prophylactic, and Diagnostic Injections and Infusions" section (90765-90779). In its place, you'll find a new section entitled "Therapeutic, Prophylactic, and Diagnostic Injections and

Infusions (Excludes Chemotherapy and Other Highly Complex Drug or Highly Complex Biologic Agent Administration)."

The codes in the new section will run from 96365 (Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; initial, up to 1 hour) through 96379 (Unlisted therapeutic, prophylactic, or diagnostic intravenous or intra-

arterial injection or infusion).

"The new codes seem to mirror the old ones in that the descriptors are practically identical," says Heather Corcoran with CGH Billing. "CPT added new introductory notes and must have wanted the codes further back in the medicine section

than where they used to be -- sandwiched between vaccine codes and psychiatry codes."

Example: Suppose a patient presents for a Remicade infusion to treat her Crohn's disease, but also undergoes hydration because she demonstrates symptoms of volume depletion.

In this situation in 2009, you'll report the hydration in addition to the Remicade infusion, which you report with chemotherapy administration codes. For the hydration, you'll report +96361 (Intravenous infusion, hydration; each additional hour [List

separately in addition to code for primary procedure]).

The old way: In 2008, for the hydration, you'll report +90761-59 (Intravenous infusion, hydration; each additional hour [List separately in addition to code for primary procedure]; Distinct procedural service). You have to include modifier 59,

because the Correct Coding Initiative (CCI) bundles hydration into the Remicade infusion, unless your physician's documentation demonstrates hypovolemia (dehydration).