Medicare Compliance & Reimbursement

Here's what physicians can and can't bill for.

Physicians who are performing a lot of digestive system surgeries will need to be more careful about billing endoscopies and colonoscopies with those procedures after July 1.

Thanks to CCI Version 10.2, CPT code 43201 (Esophagoscopy, rigid or flexible; diagnostic, with directed submucosal injection(s), any substance) will become a component of dozens of codes in the digestive surgery area, particularly repair (43300-43352), excision (43610-43641) and other procedures (43800-43865). Almost every code in these areas will be a comprehensive code with 43201 after July 1, but you'll be able to bill with a modifier.

Code 43236 (Upper gastrointestinal endoscopy including esophagus and either the duodenum and/or jejunum as appropriate; diagnostic, with directed sub-mucosal injection(s), any substance) becomes a component of many of the same excision and "other procedures" codes as 43201.

Many codes became bundled with both 43201 and 43236, including intravenous surgery codes 36005-36015, small intestinal endoscopy codes 44360 and 44376, injection codes 90782-90784 and pulse oximetry codes 94760-94761. Also, 36013-36015 became components of heart catheterization codes 95324 and 95330-95333.

Both 43201 and 43236 become components of 96570 (Photodynamic therapy by endoscopic application of light to ablate abnormal tissue via activation of photosensitive drug(s)).

Laparascopy code 44200 will be deemed a component of several other laparascopy codes for the digestive, urinary system, female genital and male genital systems (43651-43652, 44201, 47560-47561, 47570, 50542-50543, 55550, 55866, 57425, 58545-58546, 58553, 58671-58673). CPT code 44200 also became a component of 49419 (Insertion of intraperitoneal cannual or catheter, with subcutaneous reservoir, permanent), omental flap codes 49904-49905, and 50690 (Injection procedure for visualization of ileal conduit and/or ure-topyelography, exclusive of radiologic service).

Some codes become components of 45386 (Colonoscopy, flexible, proximal to splenic flexure, with dilation by balloon, 1 or more strictures) and 45340 (Sigmoidoscopy, flexible; diagnostic, with dilation by balloon, 1 or more strictures).

Sigmoidoscopy codes 45341-45345, 45378, and 45382 all become components of 45386, while manipulation codes 45900 and 45915 become components of both 45340 and 45386. Also components of both 45340 and 45386 after July 1 are fissurectomy code 46220, anoscopy code 46600 and anal fissure curettage or cautery codes 46940-46942.

Endoscopy codes 45300-45339 will all become components of 45386. Among those, 45300-45330 and 45334 will also turn into components of 45340. Meanwhile, 45340 turns into a component of colonoscopy codes 45378-45380, 45382-45385 and 45387.

It'll soon become harder to bill for anal incision code 46060 and excision codes 46258, 46262, 46270-46288 and repair code 46706. Many of those codes will have 46270-46288 and 46706 as components after July 1. Also, excision code 46220, endoscopy code 46600 and anal fissure curettage/cautery codes 46940-46942 will be components of 46706.

Manipulation codes 45900-45915, anal surgery codes 46040 and 46080 and cyprectomy code 46211 become components of 46706.

A number of digestive surgery codes also became components of omental flap codes 49904-49905, including omentectomy (49255). CPT code 56821 (Colposcopy of the vulva; with biopsy(s)) became a component of vulvectomy codes 56620-56640. And 57421 (Colposcopy of the entire vagina; with biopsy(s)) became a component of vaginectomy codes 57106-57112 and 57135.

A new code for 2004, J2001 (Injection, lidocaine HC1 for intravenous infusion, 10 mg) made it easier to bill for lidocaine in smaller quantities than the old code, J2000, which specified 50 cc quantities. But docs still have to be careful what they bill J2001 for.

Most carriers, such as Cahaba GBA, state flatly that they'll cover J2001 for intravenous injection for management of "cardiac arrhythmias and emergencies only." But Empire Medicare Services says its local coverage decision, effective late June, will also cover J2001 for intravenous regional anesthesia (or Bier Block) incident to a physician's service.

CCI 10.2 aims to reinforce that prohibition. As of July 1, J2001 is considered a component of over 1,100 surgeries and procedures. You can use a modifier to override these edits, but don't expect the carriers to be very sympathetic unless you can show that the patient had a cardiac arrhythmia, or possibly needed a Bier Block.