Gastroenterology Coding Alert

Question: We had a patient present at our practice who had been referred by his general practitioner. He’s been suffering from GERD for a while and his GP recommended the LINX Reflux Management System. Our gastroenterologist discussed the pros and cons of this with the patient, but we can’t find the code for it to research the coverage guidelines.

Codify Subscriber

Answer: Although the FDA approved the LINX system for GERD patients in 2012, insurers haven’t been as quick to approve it. Although it’s unclear which insurers you’ve been trying to research, most payers mirror the Excellus Blue Cross Blue Shield policy, which states, “Use of a magnetic esophageal ring (e.g., LINX Reflux Management System) in the treatment of gastroesophageal reflux disease (GERD) has not proven to be medically effective and is therefore considered investigational.”

However, some payers may reimburse for the service, which you’d bill with 43284 (Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (i.e. magnetic band), including cruroplasty when performed), which CPT^® introduced this year. New procedures usually receive New Technology Class III CPT^® codes for a period of 1-2 years during which time the efficacy and wider adoption of the procedure is monitored. Even after achieving standard Class I CPT^® codes, some new procedures will not be covered by commercial or Medicare carriers.

Several Part B payers, including Palmetto GBA, have published policies since 43284 was issued stating that the service is noncovered. Your best bet is to call your insurer and ask about coverage. If the patient still wants the procedure even after confirming that it’s not payable, issue an advance beneficiary notice (ABN) and explain that the patient will be responsible for paying you out-of-pocket.