Gastroenterology Coding Alert

Find out if your coding comprehension is up to date.

Once you’ve answered the quiz questions on page 3, compare your answers with the ones below.

Answer 1: For any hernia repair in the new “anterior abdominal hernia” category, you’ll report one of the following 12 new codes:

• 49591 (Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), initial, including implantation of mesh or other prosthesis when performed, total length of defect(s); less than 3 cm, reducible)
• 49592 (… less than 3 cm, incarcerated or strangulated)
• 49593 (… 3 cm to 10 cm, reducible)
• 49594 (… 3 cm to 10 cm, incarcerated or strangulated)
• 49595 (… greater than 10 cm, reducible)
• 49596 (… greater than 10 cm, incarcerated or strangulated)
• 49613 (Repair of anterior abdominal hernia(s) (ie, epigastric, incisional, ventral, umbilical, spigelian), any approach (ie, open, laparoscopic, robotic), recurrent, including implantation of mesh or other prosthesis when performed, total length of defect(s); less than 3 cm, reducible)
• 49614 (… less than 3 cm, incarcerated or strangulated)
• 49615 (… 3 cm to 10 cm, reducible)
• 49616 (… 3 cm to 10 cm, incarcerated or strangulated)
• 49617 (… greater than 10 cm, reducible)
• 49618 (… greater than 10 cm, incarcerated or strangulated)

As you can see from the descriptors, CPT^® 2023 distinguishes these new codes based on initial or recurrent, reducible or incarcerated/ strangulated, and repair size. Which brings us to the second part of the question. Each code descriptor includes a measurement that corresponds with the size of the presurgical defect.

How to measure: Measure the distance between the farthest two points. If there are multiple non-contiguous defects separated by greater than or equal to 10 cm of intact tissue, the defect size is the sum of each individual hernia.

Note: If the patient has one hernia, you’ll simply use the documented measurement of the pre-surgical hernia’s longest length and report the code that best represents that size.

Documentation alert: If the total pre-surgery defect size is not in the documentation, you must default to the code that represents the smallest size, which is 49591.

BONUS: According to the hospital procedure-to-procedure (PTP) Edit files, effective Oct. 1, 2023, column two code 49622 (Repair of parastomal hernia, any approach (ie, open, laparoscopic, robotic), initial or recurrent, including implantation of mesh or other prosthesis, when performed; incarcerated or strangulated) is now considered part of the procedures described with codes 49614 and 49615, so you cannot report them together (Source: www.cms.gov/medicare/coding-billing/national-correct-coding-initiative-ncci-edits/medicare-ncci-procedure-procedure-ptp-edits).

Answer 2: This past year, CMS lowered the minimum age requirement for colorectal cancer (CRC) screenings from 50 to 45 years.

The inclusion of comprehensive CRC screenings in the definition of CRC screening tests means that if a patient’s non-invasive stool-based test yields a positive result, Medicare will consider the follow-up colonoscopy as a preventative service. This eliminates the out-of-pocket cost for both tests. This cost-centric update, “makes the patient more at ease to follow through with more formal testing that helps better understand or quantify their condition,” says Carol Pohlig, BSN, RN, CPC, manager of coding and education in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia. Don’t forget to add KX modifier in this situation.

Answer 3: ICD-10 2024 expanded Z83.71 (Family history of colonic polyps) into four more specific codes:

• Z83.710 (Family history of adenomatous and serrated polyps)
• Z83.711 (Family history of hyperplastic colon polyps)
• Z83.718 (Other family history of colon polyps)
• Z83.719 (Family history of colon polyps, unspecified)

Remember: According to ICD-10 official guideline I.C.21.c.4, “Family history codes are for use when a patient has a family member(s) who has had a particular disease that causes the patient to be at higher risk of also contracting the disease.”

Why this is important: Properly documenting a family history of colon polyps helps justify early and more frequent screenings, like colonoscopies, which lead to early detection. Documenting family history “gives the full clinical picture for this visit by identifying the other factors that could influence decision making,” says Chelsea Kemp, RHIT, CCS, COC, CDEO, CPMA, CRC, CCC, CEDC, CGIC, AAPC Approved Instructor, outpatient coding educator/auditor for Yale New Haven Health, New Haven, Connecticut.

Until these improvements, a family history of numerous polyps not clearly identified as a specific genetic disorder like APC (adenomatous polyposis coli) or Lynch syndrome could not be very clearly coded. Having the option to code a family history of the specific type of polyp helps paint a more detailed picture for the payer, but also for future physicians.

Coding alert: It’s very possible the physician won’t know what type of polyps a family member had, so your choices will most commonly be Z83.718 and Z83.719. Don’t be surprised either if you find payer software isn’t updated to accept the six-digit codes yet, even though they were applicable as of October 1, 2023. So, Z83.71 may still be the best code until a particular payer requests more specificity.

Answer 4: CPT^® has decided to remove the time ranges from both the new and established office/outpatient E/M code descriptors and replace them with a single time that “must be met or exceeded.” This means that for codes such as 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making …), you’ll be working with a single time rather than a range.

For example, 99202 currently has a time range of 15-29 minutes. Beginning Jan. 1, 2024, the provider must meet or exceed 15 minutes of total service time before you can bill this code by time.

Note: CPT^® will not be changing the descriptor to 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional).