Gastroenterology Coding Alert

 A sampling of several BC/BS payers shows how coding requirements for the M2Acapsule can vary. Anthem BC/BS, Excellus Health, and Highmark Companies all require G0262. Wellpoint Health Networks, CDPHP, and Oxford Health all require 91299 (Unlisted diagnostic gastroenterology procedure). BC/BS Arizona requires 44799 (Unlisted procedure, intestine). Other payers, such as CareFirst BC/BS, include other codes, such as 44376 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ilium; diagnostic, with or without collection of specimens[s] by brushing or washing [separate procedure]).

Another consideration is the acceptance for G codes. Your private payer may recognize and pay for G codes. If your payer does not recognize the G code, but does have a coverage policy, you can submit a claim with the code recommended by the payer. Always check with your payer for its latest policy.

Suppose your payer doesn't recognize G codes and also has no coverage policy. Can you still be reimbursed? Given Imaging, the M2Amanufacturer, suggests that you send a letter of medical necessity to your payer prior to the procedure, because claims are reviewed individually. For reimbursement information, visit www.givenimaging.com. Under the Medical Professionals bar, click on Reimbursement, then on Payer Fact Sheet. They also provide a toll-free phone number for assistance.

It is not expected that a permanent CPT code for capsule endoscopy will be established until at least Jan. 1, 2004.

Capsule endoscopy has no global period, so the physician can receive payment for a separate, medically necessary E/M service rendered on the same day. If the procedure must be aborted, for example, because the patient has trouble swallowing the capsule, append modifier -52 (Reduced services) or -53 (Discontinued procedure). If necessary, check your CPT manual for additional description of which modifier is appropriate for the particular circumstance. If the capsule is not expelled, and must be removed endoscopically, code for retrieval with a foreign-body removal code according to the appropriate anatomic site.

Stout emphasizes that reimbursement is based on showing medical necessity. The diagnosis or clinical suspicion must be present, and you need to link a correct, payable ICD-9-CM code. You cannot use a truncated code (only three digits); use the highest level of specificity, such as 578.1 (Blood in stool, melena), 578.9 (Hemorrhage of gastrointestinal tract, unspecified) or 792.1 (Nonspecific abnormal findings in other body substances; stool). The physician must be trained in endoscopy or the test must be performed in an independent diagnostic testing facility under the general supervision of a physician trained in endoscopy procedures.

For non-Medicare payment, it's wise to check with the payer on how to bill and the reimbursement amount before performing the test, Stout says.