Gastroenterology Coding Alert

Question: My gastroenterologist used a clip to mark endoscopic tissue. I don’t see a CPT^® code for this, however. Can we bill for this?

Mississippi Subscriber

Answer: You’re right that there is no specific CPT^® code for this service. When the gastroenterologist uses a clip for endoscopic tissue marking, the only option is to use an unlisted procedure code, such as 43499 (Unlisted procedure, esophagus), 43999 (Unlisted procedure, stomach), 44799 (Unlisted procedure, small intestine), or 45399 (Unlisted procedure, colon). As the descriptors make clear, which code you choose will depend solely on where the physician puts the clip.

When reporting unlisted procedure codes, the documentation you submit with the claim needs to be robust. Payers consider these claims on a case-by-case basis. Because there is no standard fee, to improve the chances of reimbursement, it’s wise to include as much information as possible. You’ll need to clearly identify what you hope the payer will reimburse, and how you calculated that price. You’ll also want to offer a detailed description of the procedure itself. Additionally, consider showing the payer a CPT^® code with similar work and resources as a comparison to help them decide. Finally, if there is significant cost to the facility (clips aren’t cheap!), be sure to include an invoice for the supply cost to justify any extra payment when billing for the facility fee. In the example above, the extra physician time and effort may be so small as to not warrant any extra fee, whereas the facility does incur a significant extra cost.