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Gastroenterology Coding Alert

Take the Guesswork Out of Ambulatory Endoscopy Coding

Published on Sun Dec 01, 2002

Because coverage and coding guidelines for procedures performed in an ambulatory surgical center (ASC) differ from those performed in inpatient and other settings, you need to be clear on some common misunderstandings that abound regarding reimbursement for ambulatory procedures.

Gastroenterologists perform a variety of endoscopic procedures in ambulatory surgical centers. By following some simple rules, you can learn how to receive full benefits from endoscopies performed in ASCs and learn which procedures cannot be billed in this setting.

Most Endoscopies Are Covered in ASCs

According to the Medicare Carriers Manual, an ASC by definition is "a distinct entity that operates exclusively for the purpose of furnishing outpatient surgical services." These centers are either independent or operated by a hospital.

According to Stephanie Goodfellow, billing manager at Mid-America Gastro-Intestinal Consultants in Kansas City, Mo., her practice does almost all of the endoscopic procedures in the ASC setting, especially colonoscopies and upper gastrointestinal endoscopies (EGDs). She has not found it difficult to get reimbursed for these procedures. However, she warns others to be wary when filing for ambulatory services in a center that is owned by the doctor performing the surgery. She explains that their doctors "own the facility, but it is under a different name and tax ID number, and sometimes the insurance companies will get it confused as a duplicate."

Of course there will be other problems if you bill for a procedure that is not on Medicare's approved list of ambulatory procedures.

There is a list of about two-dozen procedures that are not reimbursable if performed in an ambulatory setting. Take note of some that may directly affect your practice:

  • Small intestine endoscopy series (44376-44379)
  • 45300 Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen[s] by brushing or washing
  • 45330 Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing
  • Anoscopy codes 46600-46606 and 46614-46615
  • +47550 Biliary endoscopy, intraoperative (choledochoscopy)
  • Many of the endoscopic procedure codes that include ultrasound techniques, such as 43242 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/ biopsy[s]) and 45341 (Sigmoidoscopy, flexible; with endoscopic ultrasound examination).
  • Many of the endoscopic procedures that include stent placement, such as 45387 (Colonoscopy ...; with transendoscopic stent placement [includes predilation]).
  • Many of the endoscopies that involve band ligation such as 43244 (Upper gastrointestinal endoscopy ...; with band ligation of esophageal and/or gastric varices).

    A few of these unlisted procedures may cause particular problems for gastroenterologists. Pat Stout, CMC, CPC, an independent gastroenterology coding consultant and president of OneSource, a medical billing company in Knoxville, Tenn., says the sigmoidoscopy (45330) is not approved to be performed in the ASC, but 45331 (Sigmoidoscopy, flexible; with biopsy, single or multiple) is approved. Medicare feels that 45330 is an office-based procedure only.

    "The catch-22 is that a patient can be scheduled for a sigmoidoscopy only and, once the doctor gets in there, he needs to do a biopsy or remove a polyp," Stout says. Then it becomes a covered ASC procedure. Therefore, doctors do not know whether to do it in the office or ASC setting.

    There Is Hope for More Approved Procedures

    It may seem hopeless considering that there are a few regular endoscopies that are not approved for ASCs. However, Addendum A to Medicare's ASC Payment Schedule lists proposed revisions to the ASC approved list. Included in this list is the addition of several relevant endoscopy codes: 43205 (Esophagoscopy, rigid or flexible; with band ligation of esophageal varices), 43244, 44376-44378, 45330, 46600-46606 (Anoscopy), 46614-46615 (Anoscopy), 47550 and 47556 (Biliary endoscopy, percutaneous via T-tube or other tract; with dilation of biliary duct stricture[s] with stent).

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