Gastroenterology Coding Alert

Answer: There is no code describing this procedure, although the CPT Advisory and Editorial Panels are considering adding one soon. Gastroenterologists who perform an ELGP must use the unlisted procedure code 43499 (unlisted procedure, esophagus) to report it on a medical claim, according to Cathi Coscia, an insurance clerk with Gastrointestinal Associates P.C. in Knoxville, Tenn., a practice that has performed more than 14 ELGPs in the past several months. An appropriate diagnosis code is 530.81 (esophageal reflux).

ELGP is a new procedure that was approved by the FDA in April 2000 for the treatment of gastroesophageal reflux disease (GERD). An upper gastrointestinal endoscopy is performed on the patient. At the end of the endoscope is a suturing device, manufactured by C.R. Bard Inc., which acts like a small sewing machine to create pleats in the lower esophageal sphincter muscles. The pleats serve to tighten up the sphincter and prevent reflux from flowing back up into the esophagus.

Coscia suggests that gastroenterologists precertify this procedure with private payers because many are not covering it. We called some private payers to ask if they would cover the ELGP. Instead of billing both a professional and facility fee, we asked them to cover one global fee, she explains. But very few of them would do that.

Even when insurers pay for the procedure, the reimbursement may not cover the cost of an ELGP. Most payers, even Medicare, are not even covering the cost of the suturing kit that you have to buy to do the procedure, Coscia continues. We have all the patients sign a waiver acknowledging their financial responsibility even when the payer says it will cover it.

Because this is an unlisted procedure code, a copy of the operative report must be included in the claim, as well as a letter from the gastroenterologist explaining the procedure and how its fee was derived. Sometimes Coscia has even included a copy of the invoice for the suturing kit to document to the payer what it costs.