Gastroenterology Coding Alert

New medical technologies that do not have an established CPT code, such as the Stretta procedure or endoluminal gastroplication (ELGP), should use the new Category III codes whenever possible. If no Category III code exists, an unlisted-procedure (UP) code should be reported instead of using a combination of existing codes to report a single procedure.
 
CPT 2002 includes two changes that most gastroenterology practices may have considered to be of minor importance. The first was the introduction of Category III codes, which are temporary codes assigned to emerging technologies, services and procedures. The purpose of the Category III code, which contains an alpha character at the end, is to collect data on the use of these new procedures.
 
A Category III code is not meant to indicate that a technology is experimental, explains Joel Brill, MD, a gastroenterologist and the American Gastroenterological Association representative to the CPT editorial advisory panel. These procedures have received FDA approval, but providers need to check with their carrier or private payer in advance about the reimbursement for the procedure
 
The second change was that CPT made Category III codes mandatory to ensure that the new system can gather enough data. The CPT manual reads, "If a Category III code is available, this code must be reported instead of a Category I unlisted-procedure code."

The only gastroenterology code in the Category III section so far is for ELGP (0008T, Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate, with suturing of the esophagogastric junction).
 
Note: Additional gastroenterology codes may appear in the biannual update to the Category III codes, which should be available at the beginning of July.
 
Many gastro practices that perform ELGP now bill with 43499 (Unlisted procedure, esophagus), which was correct last year. However, those practices should start reporting 0008T, whether they use the Bard EndoCinch device or another manufacturer's suturing device, Brill states. "If a Category III code exists, you have to use it," he says. "You don't have the option of using the unlisted-procedure code unless a carrier or payer has told you otherwise."

Don't Report Code Combos for a Single Procedure

There's also a new section in the introduction to CPT 2002 that reads: "Do not select a CPT code that merely approximates the services provided. If no such procedure or service exists, report the service using the appropriate UP or service code."
 
In this new text CPT is opposing using multiple codes or coding combinations to report a single procedure, Brill says. "It is becoming apparent that they [CPT and CMS] do not want code combinations used because that diminishes the use of Category III codes," he explains. "It is also becoming apparent that CMS through the Correct Coding Initiative will be putting edits in place to prevent the use of multiple codes in an attempt to describe newer technologies."
 
This is particularly confusing given that many device manufacturers, such as Curon Medical, manufacturer of the device used with the Stretta procedure, received written approval for these coding combinations from HCFA.
 
In the April 2001 issue of Gastroenterology Coding Alert on page 25, for example, it was reported that HCFA had approved the coding combination of esophagogastroduodenoscopy (EGD) with ablation code 43258 and code 64640 (Destruction by neurolytic agent; other peripheral nerve or branch) for the Stretta procedure. Curon Medical, however, was recently notified by CMS that it now prefers the UP code 43499. As a result, Curon has had to revise the reimbursement guidelines that it gives to gastroenterologists, says Carol Chludzinski, vice president of Curon Medical.
 
The problem arose because the Stretta device was in commercialization prior to being approved for an ambulatory payment classification (APC) code, which is used by facilities to claim reimbursement for supplies and equipment. "Once we got an APC code, we were told by CMS to use the UP for physician reimbursement," Chludzinski says.
 
She also points out that the UP code is just a guideline from Medicare. "Many of our customers have continued to bill the combination of 43258 and 64640 and gotten reimbursement. You have to check with your payers for the appropriate codes to use."

Brill and Chludzinski express concerns over physician reimbursement for the Category III and UP codes. Many gastroenterology practices feel that payers will view the Category III codes as experimental and not reimburse them. The other challenge is that Category III and UP codes have not been assigned a relative value unit (RVU) by Medicare, which means that these claims must be manually reviewed. The onus is put on the gastroenterologist to determine a value for the service, which is usually done by comparing it to a similar procedure. Without assigned RVUs, there is no guarantee that you will be paid.
 
Botox injections are another relatively new procedure that should be reported with the UP code unless the carrier has designated a code in its local medical review policy. Indeed, a variety of policies have been established on Botox injections, some calling for the use of EGD with injection sclerosis code 43243, but others specifying the combination of EGD code 43235 and 64640, which is appropriate because the carrier has the final say over its reimbursement policies. However, a gastroenterologist using a UP code for Botox injections will have to figure out which one to use. Various carrier policies specify using 20999 (Unlisted procedure, musculoskeletal system, general), 43499 and 90799 (Unlisted therapeutic, prophylactic or diagnostic injection).

Instead of a UP code, many gastroenterology practices report a code that is similar to the procedure in question and attach modifier -22 (Unusual procedural services). For example, many gastroenterologists report the new Given Imaging M2A capsule by attaching modifier -22 to 44376 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; diagnostic, with or without collection of specimen(s) by brushing or washing [separate procedure]). This is a legitimate option with this procedure, Brill says, because it is not a combination of codes. Another option is to report 44799 (Unlisted procedure, intestine). The claim should include an explaination of how the procedure differs from the existing code.
 
Usually the UP code is favored by gastroenterology practices over modifier -22 for reimbursement reasons. "We don't use modifier -22 unless the gastroenterologist can document that he did extra work like he removed 50 polyps from the colon or spent two hours beyond what he would normally have to on a procedure" says Cindy Poe, CPC, certified coder with Eagle Physician and Associates, a multispecialty practice with seven gastroenterologists in Greensboro, N.C. "If it's an established procedure, modifier -22 is applicable, but we use the unlisted code for new procedures like the M2A capsule."
 
Many practices find that payers tend to ignore claims with modifier -22 and that getting full reimbursement is easier with the UP codes, even though they have no RVUs attached to them. "In the past, our practice just hasn't had much luck with modifier -22," says Lois Curtis, manager of insurance and billing for Evansville (Ind.) Gastroenterology Associates.
 
Curtis adds that avoiding using UP and Category III codes with modifier -22 or coding combinations only delays the creation of new codes for CPT. "You may enter the code that is the closest to what you are doing because you don't want to mess with dictation, but then you'll never get a new code," she says. "CMS and AMA won't be able to create a new code unless you give them a reason to create a new one."

Colonoscopy with balloon dilation is another common procedure that does not have a CPT code. Some practices have tried to report this procedure with various code combinations such as the appropriate colonoscopy code and 45910 (Dilation of rectal stricture [separate procedure] under anesthesia other than local) or 45303 (Proctosigmoidoscopy with dilation), which are no longer appropriate under the new CMS and CPT philosophy. Curtis has had success with billing the appropriate colonoscopy code and billing the balloon dilation with the UP code for either the intestine (44799) or rectum (45999), based on where it was performed.
 
All UP claims require additional documentation, which Curtis includes when they are initially submitted. "We always send the operative report and a letter from the doctor with the claim," she says. "The letter explains in layman's terms what the procedure is, why it was performed and why higher reimbursement should be received. Most of it is a standard form letter that we keep on file and use every time we report the procedure."