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Gastroenterology Coding Alert

READER QUESTIONS:

Take Advantage of PDT-Specific Codes

Published on Sun Jul 10, 2005

Question: My operative notes indicate the gastroenterologist performed 75 minutes of photodynamic therapy (PDT) and used an endoscope to deliver light, but I'm unsure how to code the light application properly. What is the correct code combination for this visit?


Missouri Subscriber


Answer: To best code this claim, break it down into two parts: the endoscope procedure and the PDT itself.

Endoscope procedure: When your gastroenterologist uses the endoscope to deliver light that activates the tissue-destroying agent in Photofrin, you may be able to report an endoscopy. Gastroenterology offices commonly use the following codes to report endoscope use during PDT.

On your claim, choose one of these codes to represent the endoscopy:

  • 43228 - Esophagoscopy, rigid or flexible; with ablation of tumor(s), polyp(s), or other lesion(s), not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique

  • 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.

    PDT: Since the start of this decade, the CPT manual has included codes to represent the light used during PDT. On your claim, you should: 

  •  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 esophagus]) for the first 30 minutes of illumination.

  •  report +96571 x 3 (... each additional 15 minutes [list separately in addition to code for endoscopy or bronchoscopy procedures of lung and esophagus]) to account for the remaining 45 minutes of illumination.
     
    These are add-on codes and will be attached to the endoscopy code, so you do not need to provide any modifiers on the claim.

    Never do this: If you look for PDT in CPT too quickly, you may make a coding mistake that results in denial. Above the add-on codes for PDT in CPT 2005 sits the deceptive 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).

    You should never report this code for PDT that a gastroenterologist provides. Code 96567 is for physicians who provide external PDT, but gastroenterologists perform endoscopic PDT.

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