Gastroenterology Coding Alert

Medical necessity should be the governing factor -- not depth or scope type

If you're routinely coding every scope procedure your gastroenterologist performs as a push enteroscopy, your coding could land you in hot water.

The catch: Just because your gastroenterologist goes past the proximal duodenum doesn't mean you should always report an enteroscopy (44361, Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with biopsy, single or multiple). Sometimes an esophagogastroduodenoscopy (EGD) code, such as 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple), is the correct code to report.

Follow this expert advice to ensure you're choosing the proper scope code every time, and bring in the reimbursement your gastroenterologist deserves.

Confirm Clinically Indicated Depth Before Coding

Clinical practice doesn't necessarily equate to coding. You can only bill for how far the physician goes if the documentation shows there's a medically necessary reason. Patient chart notes must indicate the clinical reason for going that far.

Pitfall: Just because a physician was trained in medical school or as a routine practice to always go past duodenum to take a peek, doesn't mean you can always bill for the extra distance using 44361. An auditor examining a note will only allow payment for what is medically indicated.

Reasoning: The American Society for Gastrointestinal Endoscopy (ASGE) Coding Primer: A Guide for Gastroenterologists states, "If an endoscope happens to be passed into the proximal jejunum during a routine upper endoscopy due to a short duodenum or altered anatomy it does not automatically enable the use of these codes." Focus on one key detail to determine whether you'll report a push enteroscopy code or an EGD code. The ultimate depth that the endoscope reaches that is medically necessary will determine which family of endoscopy you use to report the procedure, explains Jenny Berkshire, CPC, CGIC, CEMC, a compliance manager at Wright State Physicians in Dayton, Ohio.

To determine your scope code, follow these guidelines:

• To report an endoscopic examination of the esophagus, use codes from the parent code 43200 (Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen(s) by brushing or washing [separate procedure]), even if the gastroenterologist incidentally enters the stomach -- for example, if the physician needs to gain a retroflex view back at the cardia, says Glenn D. Littenberg, MD, a CPT Advisor with ASGE in Pasadena, Calif.

• When your gastroenterologist passes the pylorus with the endoscope, you'll choose a code from the 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) set, says Berkshire. In altered anatomy, such as a Billroth II or gastric bypass situation, the gastroenterologist enters the jejunum but the EGD codes (43235 section) are still most appropriate, Littenberg explains.

• Once the scope passes the second portion of the duodenum, you can use codes from parent 44360 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, with or without collection of specimen(s) by brushing or washing [separate procedure]). When the scope passes to the ileum, use codes from parent 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]), Berkshire says. To appropriately report codes from the 44360 series, you have to have medical necessity to examine the jejunum. The physician typically accesses well beyond the ligament of Treitz area and well into the jejunum, Littenberg warns.

Tip: "One should also be familiar with the Correct Coding Initiative (CCI) edits which do not allow payment for the base EGD code (43235) with the small bowel endoscopy code (44360) because the standard endoscopy procedure is included in the small bowel endoscopy code by definition," says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel. "The CCI edits also forbid coding 43239 with 44361, but in that case there is '1'  modifier with that edit indicating that under unusual circumstances it might be possible to use both codes. If two different instruments were needed for two different indications then it may be possible to bypass the edit with a 59 modifier (Distinct procedural service), the appropriate documentation, and, if needed, an appeal," Weinstein says.

Don't Let Scope Type Thwart Your Coding

Hidden trap: Occasionally, the physician may employ a pediatric colonoscope for an EGD due to a patient's anatomy. You will still report an EGD code for this procedure.

Typically a gastroenterologist uses a pediatric colonoscope to reach the jejunum in push enteroscopy because its length provides deeper access than can be accomplished with the standard upper gastrointestinal (UGI) endoscope, Littenberg says. But that's not always the case.

Bottom line: "The type of scope does not determine which family of codes is used," Berkshire says.

Less is More -- Sometimes

Logically, you might assume that since the push enteroscopy goes deeper, you would always get paid more for that procedure versus the EGD. Oddly enough, going farther doesn't always net you more money. That point confuses many coders, says Weinstein.

How it works: The AMA considers an upper endoscopy with biopsy safe to perform in the office. Therefore, your gastroenterologist may perform the procedure in a "non-facility" setting. Since  here is a significant additional practice expense payment for 43239, you'll actually earn more for the EGD in the office than you earn for the push enteroscopy -- which can only beperformed in a facility setting -- even though the push enteroscopy goes farther.

The math: CMS assigns 4.75 relative value units (RVUs) for 44361 in the facility setting. Code 43239 has only 4.72 RVUs in a facility setting but 9.05 in a nonfacility setting (based on the 2010 Medicare Physician Fee Schedule, which pays 36.0846 per RVU).