Part B Insider (Multispecialty) Coding Alert

Question: Our gastroenterologist recently treated a patient with Solesta injection for fecal incontinence. Since there is no CPT^® code for the procedure, I tried using 46999 along with L8605 for the supply of Solesta. However, this claim was denied. Please tell me if there is any other code for the procedure or if I have done anything wrong?

Answer: As you have correctly pointed out, there is no separate CPT^® code for a submucosal injection that is administered by your gastroenterologist to treat fecal incontinence. So, you have no other option but to use the unlisted code 46999 (Unlisted procedure, anus) to report this procedure and to report L8605 (Injectable bulking agent, dextranomer/hyaluronic acid copolymer implant, anal canal, 1 ml, includes shipping and necessary supplies) for the Solesta supply.

To improve the chances of payment, it is best that you check with the payer regarding payer policies for this method of treating fecal incontinence. Check with them if the particular procedure is covered, and if so, what documentation is required to enable coverage for the procedure.

Some payers may require you to fill in the Box 24A of the CMS-1500 form to include the national drug code qualifier N4, followed by the 11-digit national health-related items code (NHRIC, 89114-0850-03). The payer might also need you to fill in the unit of measure, number of units and price per units.

The payer will probably tell you to remember to attach documentation of other, more conventional attempts at treatment for fecal incontinence, such as using fiber or biofeedback. You may not get any payment if your practitioner has not tried other conventional methods of treatment prior to trying out this procedure.

You will also need to include proper diagnosis codes such as 307.7 (Encopresis [continuous] [discontinuous] of nonorganic origin) and 787.6 (Incontinence of feces) to enable the payer to know that the treatment was done for fecal incontinence.

Note: If you are coding for payment through Outpatient Prospective Payment System (OPPS), effective April 1, 2013, there is a separate HCPCS code C9735 (Anoscopy; with directed submucosal injection[s], any substance) to report administration of Solesta. You can also use this code with the payment indicator G2 (Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight) if you are coding for an ambulatory surgical center (ASC).