Gastroenterology Coding Alert

Question: Our gastroenterologist used India ink to mark two lesions she removed by snare technique during a colonoscopy. I have heard stories about gastroenterology offices getting reimbursed for India ink tattooing, but I’m skeptical. Should I report the tattooing or just stick with the base colonoscopy?

Codify Subscriber

Answer: Unfortunately, there’s no universal answer to this question, and the rules will depend on the payer.

Although India ink tattooing is undeniably valuable to the patients who need it, Medicare does not reimburse specif­ically for it. To further complicate things, you won’t find any specific CPT^® code for the procedure, leaving coders with few choices. However, you do have a code for a colonoscopy with injection -- and this could be your ticket to India ink payment.

If the GI performed no other therapeutic service, then report only one code: 45381 (Colonoscopy, flexible; with directed submucosal injection[s], any substance) for the colonoscopy and the India ink tattooing.

The Correct Coding Initiative (CCI) does not bundle 45381 into any other colonoscopy code, so you can bill it without a modifier.

Medicare should reimburse for the additional injection service above the base colonoscopy code. But some commercial carriers may deny the additional service and consider it included in the higher-valued code. When you know this in advance, add the 59 modifier (Distinct procedural service) to the submucosal injection code and try to add some verbiage in a text field “separate service.”

You may also have to appeal a denied claim to receive full payment for a colonoscopy with India ink tattooing, at least initially. If you file an appeal, make sure to include a separate letter containing cost estimates of the procedure, including materials and supplies used and the additional nursing time required, if any.

An appeal takes a lot of time, but if you do it properly and the payer recognizes India ink tattooing once, the payer is more likely to accept future tattooing claims on good faith. Of course, if a payer has laid out its reasons for not reimbursing India ink tattooing, stop coding for the procedure with that payer.