5 Best Practices for the Correct Coding and Billing of GI Procedures
Here are five best practices to help you overcome some challenges GI coding and ensure your ASC is properly reimbursed for the procedures your surgeons perform.
1. Upper-GI dilation procedures
Some patients will require dilation procedures when their esophagus becomes closed because they suffer from such problems as esophageal varices, achalasia, reflux esophagitis (GERD), problems after radiation therapy for esophageal cancer, scarring from drinking of poisons, certain medications that can cause ulcerations and esophageal “webs.” Some dilation procedures are performed with endoscopy, and coded from the appropriate endoscopy codes. Some are not, and when they are not, they are called manipulations (codes 43450 through 43458). These procedures may require the use of bougies, which are flexible dilators with different sizes increasing in thickness.
When performing bougie dilations, if an esophagogastroduodenoscopy (EGD) is performed before a bougie dilation (where the physician does not perform the procedure through an endoscope) and if a diagnostic endoscopy is performed before the dilation,it would be coded as 43235-59 (per the AMA CPT Assistant).
For the dilation, use code 43450 for a dilation of the esophagus by unguided sound or bougie, single or multiple passes, or code 43453 for a dilation of the esophagus over a guidewire. For dilation procedures performed with a balloon, use codes 43456, 43458 or 43460, as appropriate.
When performing an esophagoscopy, rigid or flexible; with balloon dilation (less than 30-mm diameter), code 43220, the measurement refers to the maximum diameter of the balloon itself, not the diameter of the esophagus.
2. PEG tube codes
Codes for percutaneous endoscopic gastrostomy (PEG) tubes or jejunostomy tubes (J-tubes), which can also be referred to as buttons, are as follows:
• Code 43246 — Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube.
• Code 49440 — Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s).
• Code 49441 — Insertion of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s).
• Code 49450 — Replacement of gastrostomy or cecostomy (or other colonic) tube, percutaneous, under fluoroscopic guidance including contrast injection(s).
• Code 43760 — Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance.
• Code 43269 — Endoscopic retrograde cholangiopancreatography (ERCP); with endoscopic retrograde removal of foreign body and/or change of tube or stent.
• Code 49451 — Replacement of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s).
• Code 49452 — Replacement of gastrojejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s).
Mechanical removal of tube obstructions:
• Code 49460 — Mechanical removal of obstructive material from gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, any method, under fluoroscopic guidance including contrast injection(s), if performed.
• Code 43870 — Closure of gastrostomy, surgical.
Note: Stitches must be placed with a surgical closure to use this code. If no stitches are placed, and the tube is pulled and steri-strips are put over the gastrostomy opening, use the 49999 unlisted-GI code.
3. Colonoscopy procedures scheduled as screening with subsequent invasive procedures
Sometimes cases are scheduled as screening colonoscopy procedures, but the physician finds a polyp or performs a biopsy during the procedure, which changes the coding of both the diagnosis and CPT codes for billing. The latest Medicare guidance for the situation where a colonoscopy is scheduled as a screening colonoscopy, but a polyp is removed and/or a biopsy is taken is to not bill the G-code for a screening procedure but bill the appropriate CPT codes for the procedure(s) performed (45385, etc.).
On the claim listing of the diagnoses, sequence the screening V76.51 code first, followed by the 211.3 polyp or other appropriate diagnosis code. When linking the diagnosis to the procedure on the claim form, only link the 211.3 polyp or other pertinent code with the 45385 or other colonoscopy procedure code and do not link the screening V-code in field 24E to any procedure code billed.
4. Scheduling of colonoscopy procedures
When scheduling colonoscopies, it is important to know if the patient has symptoms or if it is a screening colonoscopy procedure only. Reimbursement can vary significantly based on what was performed. What can start out as a screening study can be entirely different after the procedure is performed. If a screening study turns into a biopsy or polypectomy procedure, not only will the coding change, but the patient’s benefits may be different, possibly increasing how much out-of-pocket the patient will owe. This benefits issue affects those patients with insurance other than Medicare more than it does Medicare patients.
At the time that the colonoscopy is scheduled, the ASC’s scheduler should find out from the physician’s office if the colonoscopy is being performed for symptoms or as a screening procedure only. If it is scheduled as screening, when performing insurance verification, it is very important to ask for the benefits information using very specific language, obtaining the benefits for both screening and diagnostic/surgical colonoscopy procedures.
Explain the benefits for both types of colonoscopy studies to the patient, so that he understands how much the he will owe in both scenarios — whether the test turns out to be a screening or diagnostic/surgical study. It is very important for the patient’s benefits to be properly explained to the patient before the procedure is performed. Patient’s financial responsibility information should be given to the patient in writing and should detail both benefit possibilities (screening and diagnostic/surgical benefits, if they differ). It is important to let patients know they have an obligation to pay what they owe and that what they owe can change based on what occurs during a colonoscopy procedure.
Detailed scheduling and insurance verification procedures are very important on these types of procedures. Your facility’s reimbursement fate is in your own hands. Detailed work on the front-end and proper/thorough explanations to the patient up-front can save your facility from bad feelings and adverse patient reactions after the procedure if the patient owes more than he/she expected.
5. Colonoscopy procedures
The screening procedures for Medicare high risk patients (code G0105) are covered every 24 months. This category for colon cancer means a personal or family history of polyps or colon cancer. Medicare’s definition of “family history” only includes the following blood relatives: parents, siblings or children.
The screening codes for non-high risk Medicare patients (code G0121) is covered once every 10 years. If the physician detects a growth and performs a biopsy or polyp removal during the colonoscopy, code the appropriate CPT code for the procedure based on the method the physician used and do not code the screening G-code. When there are two or more lesions biopsied or excised, bill the code for each technique used (biopsy and polypectomy method) once, regardless of the number of lesions removed, as each code is for the removal of a single or multiple lesions.
For example, if the colonoscopy is scheduled as a screening study on a Medicare patient and the GI physician takes three biopsies, removes two polyps by hot snare method, does tattooing of one lesion and removes three polyps using the hot biopsy forceps method, the coding would be as follows:
• Use code 45385 (once) for the snared polyp excisions.
• Use code 45381 for the lesion which was tattooed.
• Use code 45384-59 (once) for the polyps excised by hot biopsy forceps. This code must be billed with the -59 modifier because it is unbundled from the 45385 code in the CCI mutually exclusive table, but is separately billable because the three polyps removed by hot biopsy forceps were in different areas than those removed by snare.
• Use code 45380-59 (once) for the three areas biopsied. This code must be billed with the - 59 modifier because it is unbundled from the 45385 and 45384 codes in the CCI table, but is separately billable because the three biopsies taken were in different areas than the polyps removed.
• Code diagnoses as follows: Use code 233.1 for the colon polyps, 562.10 for diverticulosis seen during the procedure and code V76.51 for a screening study since the colonoscopy was scheduled as a screening procedure.
CPT codes are copyrighted by the AMA.
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