2010 CPT Coding Changes Analysis for Gastrointestinal Services in ASCs

CPT copyright 2008 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Excision of rectal tumor
▪ 45171 — Excision of rectal tumor, transanal approach; not including muscularis propria (i.e., partial thickness). The reimbursement is approximately $565.
▪ 45172 — Excision of rectal tumor, including muscularis propria (i.e., full thickness). The reimbursement is approximately $960.

Codes 45171 and 45172 are new, replacing the now deleted CPT 45170. CPT 45171 is for partial-thickness excision of rectal wall tumors, which are typically small or benign and not amenable to endoscopic excision. CPT 45172 is reported for full-thickness excision of rectal wall tumors, which are typically larger than those removed via partial thickness.

Anus section of CPT surgery
There are extensive and important changes within the anus section of CPT surgery. The instructional guidelines, presented here, are new and assist in gaining a snapshot of the important changes.

▪ 46083 — Incision of thrombosed external hemorrhoid
▪ 46200 — Fissurectomy, including sphincterotomy, when performed. This code has been revised with the removal of "with or without" spincterotomy, because a spincterotomy is typically performed with this procedure. The reimbursement is approximately $826.
▪ 46221, 46945, 46946 — Ligation of internal hemorrhoids
▪ 46250-46262, 46320 — Excision of internal and/or external hemorrhoids
▪ 46500 — Injection of hemorrhoids
▪ 46930 — Destruction of internal hemorrhoids by thermal energy
▪ 46999 — Destruction of hemorrhoids by cryosurgery.
▪ 46947 — Hemorrhoidopexy

Hemorrhoidectomy procedures
▪ 46221 — Hemorrhoidectomy, internal, by rubber band ligations. This reimbursement pays $105.
▪ 46945 — Hemorrhoidectomy, internal, by ligation other than rubber band; single hemorrhoid column/group. The reimbursement is approximately $132.
▪ 46946 — 2 or more hemorrhoid columns/groups. The reimbursement is approximately $503.
▪ 46250 — Hemorrhoidectomy, external, 2 or more columns/groups. The reimbursement is approximately $842.
▪ 46255 — Hemorrhoidectomy, internal and external, single column/group
▪ 46260 — Hemorrhoidectomy, internal and external, 2 or more columns/groups.

Codes 46221, 46945 and 46946 are for coding internal hemorrhoidectomy procedures. CPT 46221 is for rubber band ligation and CPT 46945/46 are using other than rubber band ligation. Codes 46945/46 have been relocated from the suture section since it does not involve sutures.
These codes, along with CPT 46250, 46255 and 46260, are revised to note the number of column. Note: See the illustration in the CPT codebook.

Lastly, a cross-reference note has been included to direct users to the unlisted code 46999 to identify removal of a single external-only column via hemorrhoidectomy.

Excision of papilla or tags
▪ 46220 — Excision of single external papilla or tag, anus. The reimbursement is approximately $503.
▪ 46230 — Excision of multiple external papillae or tags, anus. The reimbursement is approximately $800.

Because these two codes involve similar work, the language for CPT 46230 has been changed to complement the language for code 46220. CPT 46220 can be used to identify single papilla or tag removal while CPT 46230 can be used to identify removal of multiple tags or papillae.

Surgical treatment of anal fistula
▪ 46275 — Surgical treatment of anal fistula (fistulectomy/fistulotomy); intersphincteric. The reimbursement is approximately $842.
▪ 46280 — Transsphincteric, suprasphincteric, extrasphincteric or multiple, including placement of seton, when performed. The reimbursement is approximately $871.

Code 46275 has been revised by replacing the term "submuscular" with "intersphincteric" to more specifically define the service performed. On the other hand, code 46280 was changed to better describe procedures included as "complex" treatment of an anal fistula, but "complex" has been replaced with the phrase "transsphincteric, suprasphincteric, extrasphincteric."

Repair of anorectal fistula
▪ 46707 — Repair of anorectal fistula with plug – that is, a porcine small intestine submucosa, or SIS. The reimbursement is approximately $1,209.

While code 46707 is new, this is not a new procedure. It replaces Category III code 0170T. This is for the surgery that — through a minimally-invasive, sphincter-sparing option — treats anal fistulae. In this procedure, the fistula tract of an SIS-derived "plug" is placed so that it spans the entire length of the fistula tract from the internal to the external opening to support healing and closure. The plug is sutured in place at both the internal and external openings.

Placement of interstitial device
▪ 49411 — Placement of interstitial device(s) for radiation therapy guidance (e.g., fiducial markers, dosimeter), percutaneous, intra-abdominal, intra-pelvic (except prostate), and/or retroperitoneum, single or multiple. The reimbursement is approximately $281.

This is a new code to describe placement of an interstitial device, such as a fiducial marker or dosimeter, using any of a varying number of approaches. The interstitial device is placed for the purpose of radiation therapy guidance. Code 49411 is reported only once, regardless of the number of devices placed.

Repositioning of a feeding tube
▪ 43761 — Repositioning of a naso- or oro-gastric feeding tube, through the duodenum for enteric nutrition. The ASC reimbursement is approximately $342.

This code has been changed to simply highlight that it is to be used for repositioning of the naso- or oro-gastric feeding tube. The 2009 description did not include naso- and oro-.

FYI: Changed laparoscopy codes (not covered in an ASC)
▪ 43281 — Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh
▪ 43282 — Laparoscopy with implantation of mesh
▪ 43775 — Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy

How to apply this knowledge
1. Learn which codes have been deleted, added or changed.
2. For any charge tickets with obsolete codes, cross through the deleted codes so if an older charge ticket is used, it doesn't contain an outdated code that will be rejected.
3. Study the new codes and determine what kind of physician education or querying might be needed. Coders based at the ASC might want to contact staff at the physician's office to see which new codes would most impact the practice. Then determine which of those will be performed in the ASC.
4. If you know of any 2009 cases that might fit the new codes, pull the documentation to see if it is appropriate for the new codes. This also applies to codes with changed descriptions. You might find there are areas where documentation needs improvement, in which case you'll need to work on that with the physicians.
5. Determine what financial impact the changes will have on your center. Do you need to re-focus your marketing to physicians and the community?

Contact Susan Garrison, executive vice president for healthcare consulting services at Magnus Confidential in Dawsonville, Ga., at seg@magnusconfidential.com.
The information provided should be utilized for educational purposes only. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.

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