Gastroenterology Coding Alert

Question: Since the 2005 CPT manual included a permanent code for the Stretta procedure, our gastroenterologist asked us to do some research on payer acceptance for claims using the new code. (She won't consider purchasing equipment to perform Stretta tests until she gets some hard data.) How has reimbursement been for the new Stretta code?

Louisiana Subscriber

Answer: Your office was wise to wait on purchasing equipment for the Stretta procedure; even with its own permanent code, you still must strain (and endure pain) when reporting Stretta.

Coding experts were cautiously optimistic when CPT 2005 included a new code for endoscopic treatment of gastroesophageal reflux disease (GERD), but even that optimism hasn't been rewarded by payers. Yet.

The new code for the Stretta procedure, 43257 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease), replaced 0057T (Upper gastrointestinal endoscopy, including esophagus, stomach, and either the duodenum and/or jejunum as appropriate, with delivery of thermal energy to the muscle of the lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease), which was used to report Stretta in 2004.
 
But as the CPT disclaimer says, the presence of a code doesn't guarantee reimbursement. And one carrier has already come out with a draft local coverage decision stating that it won't pay for 43257 under any circumstances.

Noridian says it will consider the Stretta procedure "not yet proven effective" until more clinical data come in. The procedure remains controversial in the medical community because there are no data on long-term effects.

Best bet: Wait a little longer, and do some more research, before deciding whether to buy Stretta equipment. Call your individual carriers, talk to a representative, and ask if the carrier is accepting 43257 for the Stretta procedure.