Gastroenterology Coding Alert

Question: Our gastroenterologist performed photodynamic therapy (PDT) for one hour on a patient with Barrett's esophagus. We reported 96567 and were denied. What did we do wrong?

Connecticut Subscriber

Answer: Simply put, you used the wrong PDT code.

As its explanation indicates, code 96567 (Photodynamic therapy by external application of light to destroy premalignant and/or malignant lesions of the skin and adjacent mucosa [e.g., lip] by activation of photosensitive drug[s], each phototherapy exposure session) is for external PDT, and the PDT the gastro performed was endoscopic, meaning you should not report an external PDT code.

When a gastro administers PDT endoscopically, you should file a claim with a minimum of two codes: one for endoscopy and (at least) one for the illumination of the cancerous cells in the patient.

If your gastroenterologist performs one hour of PDT on a patient, you should:

• Report 43228 (Esophagoscopy, rigid or flexible; with ablation of tumor[s], polyp[s], or other lesions[s], not  amenable to removal by hot biopsy forceps, bipolar cautery or snare technique) for the endoscopy.

(Note: In some cases, you can use 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].)

• Attach ICD-9 code 530.85 (Barrett's esophagus) to 43228.

• Report +96570 (Photodynamic therapy by endoscopic application of light to ablate abnormal tissue via activation of photosensitive drug[s]; first 30 minutes [List separately in addition to code for endoscopy or bronchoscopy procedures of lung and gastrointestinal tract]) for the first half-hour of light application.

• Report +96571 x 2 (... each additional 15 minutes [List separately in addition to code for endoscopy or bronchoscopy procedures of lung and gastrointestinal tract]) for the second half-hour of light application.

Remember: Since these are add-on codes, you do not need to report any modifiers.