Part B Insider (Multispecialty) Coding Alert

Don't try to bill separately for esophageal dilation

If your physician routinely performs endoscopies that include extra work to dilate the esophagus or collect specimens, then you may have just lost the ability to bill for that extra work.
 
New edits target gastroenterology testing codes 91000 (Esophageal intubation and collection of washings for cytology, including preparation of specimens (separate procedure)), 91055 (Gastric intubation, washings, and preparing slides for cytology (separate procedure)) and 91105 (gastric intubation, and aspiration or lavage for treatment).

The most heavily affected code is 91000, which will become a component of 36 endoscopy codes, every single code from 43200 to 43259. In other words, when performing an esophagoscopy, your physician will no longer be able to bill separately for esophageal intubation and specimen collection for cytology.

Fewer edits affect 91055, which is only a component of 43234-43259, and 91105, which is only a component of 43200-43201 and 43234-43239. But none of these edits can be overridden with a modifier, except for the ones affecting 91105.

"The edit is absolutely appropriate," says Joel Brill, a physician in Scottsdale, Ariz. CPT Codes 91000, in particular, was intended for cases when "a specimen collection was being obtained because that patient wasn't undergoing an endoscopy." But if you're billing endoscopy codes as well, "you're already performing that service as part of your upper endoscopy," Brill notes. "Medicare has said many times that you can't get paid twice for doing the same thing."

Separately, 43450 (Dilation of esophagus, by unguided sound or bougie, single or multiple passes) and 43453 (Dilation of esophagus, over guide wire) both became components of 43248 (Upper gastrointestinal endoscopy, with insertion of guide wire followed by dilation of esophagus over guide wire) and 43249 (...with balloon dilation of esophagus (less than 30 mm diameter)). You can't use a modifier to override these edits.

This is a similar situation, says Brill. The physician has already done the endoscopy and placed a guide wire in order to perform a service, so you shouldn't be billing separately for dilating the esophagus.

"CCI edits are instituted for a number of reasons, but one of the reasons is that when the folks at CMS and at the contractors analyze the database, if they notice certain billing patterns taking place for which there is no good or logical explanation, that's what prompts them to do the edit," adds Brill.