A. We have received numerous communications regarding this issue. The conflict stems from Medicare's [original] instructions for diagnostic tests which states "Diagnostic tests ordered in the absence of signs and/or symptoms (e.g., screening tests)…the testing facility or the physician interpreting the diagnostic test should report the screening code as the primary diagnosis code. Any condition discovered during the screening should be reported as a secondary diagnosis." The Coding Clinic referenced this statement to instruct their subscribers to use the screening ICD-9 code as primary for colonoscopies.

However, the AHA left off the last part of the Medicare instructions which states "This instruction does not supersede statutory payment guidelines (i.e., Medicare's screening colonoscopy or sigmoidoscopy reporting guidelines). If, during the course of a screening colonoscopy or sigmoidoscopy a lesion or growth is detected, the lesion or growth should be reported as the primary diagnosis, not the reason for the test." By this logic, the primary ICD-9 code should be the lesion not the screening for both the hospital and the physician.

CMS eventually clarified their intent and gave more explicit instructions, in a MedLearn article that we cite below. The problem became more complex when Congress instructed CMS not to charge a deductible for colonoscopy when the result was screening and not therapeutic; but to charge the deductible when the procedure becomes therapeutic! Attempts to alter this unwise policy require further legislation and is a subject of ASGE advocacy.

In the MedLearn article instruction, the KEY GUIDANCE is:

TAKE HOME MESSAGE:
When a diagnostic colonoscopy for screening (G0121 or G0105) becomes therapeutic because of a finding, use the CPT code reflecting the procedure performed—e.g. 45385 (line 24 of the 1500 claim form); list V76.51 or similar ICD-9 indicating SCREENING intention of the procedure as the FIRST DIAGNOSIS; list the finding e.g. 211.3 polyp as the second diagnosis; BUT, in line 24E where the CPT code “points to” the diagnosis pertinent which is in box 21, reference the SECOND diagnosis! (the polyp or finding)

Why? Because the V code reflects the primary intention; but most payers will reject the therapeutic code like 45385 if the V code is the only or first diagnosis pointed to.

IF your particular payer still rejects the claim because V76.51 is listed first, then reverse the sequence. It still tells the payer that screening was the original intent. Many private payers have coverage policy that allows benefits for the screening, yet will deny the claim if billed as therapeutic WITHOUT the screening V code!

Coding for Polypectomy Performed During Screening Colonoscopy or Flexible Sigmoidoscopy 

MLN Matters Number: SE0746

CMS has become aware of confusion regarding billing for colorectal screening arising because of wording in the Medicare Physician Fee Schedule (MPFS) Final Rule for 2007 (Federal Register, Vol. 71, No. 231, page 69665, December 1, 2006).

See the MPFS Final Rule on the CMS website

The relevant section of the 2007 MPFS states, regarding screening colonoscopies, that:

“If during the course of such screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the lesion or growth, payment under this part shall not be made for the screening colonoscopy but shall be made for the procedure classified as a colonoscopy with such biopsy or removal.''

Based on this statutory language, in such instances the test or procedure is no longer classified as a "screening test." Thus, the deductible would not be waived in such situations.

The above scenario can be restated as follows:

• A patient presents for a screening colonoscopy (or flexible sigmoidoscopy), and the patient has no gastrointestinal symptoms.
• During the subsequent screening colonoscopy (or flexible sigmoidoscopy), an abnormality is identified (such as a polyp, etc.), and it is biopsied or removed.

CMS advises that, whether or not an abnormality is found, if a service to a Medicare beneficiary starts out as a screening examination (colonoscopy or sigmoidoscopy), then the primary diagnosis should be indicated on the form CMS-1500 (or its electronic equivalent) using the ICD-9 code for the screening examination.

As an example, the above scenario should be billed as follows using claim form CMS-1500 (or its electronic equivalent):

• Item 21 (Diagnosis or Nature of Illness or Injury)
• Indicate the Primary Diagnosis using the International Classification of Diseases, Ninth Revision, Clinical Modification, (ICD-9-CM) code for the screening examination (colonoscopy or sigmoidoscopy), and
• Indicate the Secondary Diagnosis using the ICD-9-CM code for the abnormal finding (polyp, etc.).
• For example, V76.51 (Special screening for malignant neoplasms, Colon) would be used as the first listed code, while the secondary code might be 211.3 (Benign neoplasm of other parts of digestive system, Colon).
• Item 24D (Procedures, Services, or Supplies)
• Indicate the procedure performed using the CMS Healthcare Common Procedure Coding System/Common Procedure Terminology (HCPCS/CPT) code for the procedure (biopsy or polypectomy), and
• Item 24E (Diagnosis Pointer)
• Enter only "2" (to link the procedure (polypectomy or biopsy) with the abnormal finding (polyp, etc.)

A Medicare beneficiary undergoing a screening colonoscopy (no symptoms and no abnormal findings prior to the procedure) will be responsible for the deductible if a polyp is identified and either biopsied or removed.

When there is no need for a therapeutic procedure, the appropriate HCPCS G-code is reported with the ICD-9-CM code reflecting the indication. Effective January 1, 2007, CMS began waiving the annual Medicare Part B deductible for colorectal cancer screening tests billed with the HCPCS G-codes.

We also cite an explanation from a few years ago from CMS official Terrence Kay: “The correct way to bill for the procedure is to list the V code as the first diagnosis and the polyp as the second in Box 21 of the CMS 1500 claim form. Coders should enter a "2" in Box 24E next to the procedure for the polypectomy or biopsy, linking the second diagnosis with the procedure.”

As per Mr. Kay, "the current (CMS) 1500 instructions indicate, for item 21: 'Enter up to four codes in priority order (primary, secondary condition).' For 24 E, the instructions state: 'Enter the diagnosis code reference number as shown in item 21 to relate the date of service and the procedures performed to the primary diagnosis. Enter only one reference number per line item. When multiple services are performed, enter the primary reference number for each service, either a 1, or a 2, or a 3, or a 4. This is a required field.' It does NOT say you have to list the 'primary' diagnosis from box 21 on each box 24E line item. It goes so far as to say you can choose among the four dx codes listed."

A. Maybe! If the snare tip was used to fulgurate a tiny polyp without biopsy, no separate code would be appropriate. If a hot biopsy forcep was utilized to remove tissue and fulgurate the remaining polyp, the coding would be 45385 for the snare excision, and 45384-59 (Medicare) or 45384-51 +/or –59 for the commercial payor, depending on how they cover and value the 2nd procedures during the same setting.

A. No. In this case, if snare removal (hot or cold) was the method for removal of all polyps, you can only charge the code once as it states "polyp(s)" in the CPT description. If multiple polypectomy was performed which required several different techniques that are not represented by the same code, then the physician could charge for the various techniques used, reporting the secondary lesser valued code(s) with –59 modifier, indicating “distinct procedural services.”

A. A biopsy can mean that either part or that an entire specimen is removed; so the correct code during colonoscopy is 45380 and during EGD, 43239.

A. Choices are 43202, esophagoscopy with directed submucosal injection(s), any substance; or the EGD counterpart 43236. The former would be sensible if a prior diagnostic endoscopy was done which established the diagnosis, and there is no new medical necessity to reexamine stomach and duodenum. The latter might be done, for example, if a patient with prior Botox treatment required a follow-up exam after a long interval and it was medically sensible/necessary to re-examine stomach, duodenum. Separate reporting of the Botox drug is allowed.

(For more information on this subject, see Chapter 4 in Coding Primer: A Guide for Gastroenterologists, 2009)

A. Assuming you billed the colonoscopy code first (being higher valued), and second procedure with either modifier 51 to indicate multiple procedures, or without modifier (since most payers don’t require modifier 51 to pay a second procedure), the question is what was the reason on the remittance notice for the denial?

CMS and most payers will reimburse 50 percent of the usual allowance for the second procedure, which is why the higher valued procedure is billed first, regardless of the order in which they were performed. The best recourse is to contact the payer if you can’t tell why the second procedure was denied; or appeal if there appears to be an inappropriate reason for denial. If you can find another remittance from the same payer where the same code pair (or something close, a colon code and an upper code) were both paid, enclose a copy to show the payer they are being inconsistent. If they still refuse to pay and it appears to contradict any existing contract, the patient may well remain responsible for your usual fee and have to appeal directly to the payer, or complain to the state regulatory agency with jurisdiction. Most of the largest national payers have settled class action suits brought by state medical societies in which they have agreed to abide by recognized CPT coding and CMS payment conventions. Let ASGE know when you’ve encountered payers who don’t appear to be playing by the rules we expect so we can investigate and advocate for change!

(For more information on this subject, see Chapters 2-3 in Coding Primer: A Guide for Gastroenterologists, 2009)

A. No. The -50 modifier indicates that a procedure was performed bilaterally. That means that the exact same procedure was performed on both sides of the anatomically identical parts of the body—this modifier is never applicable in GI endoscopic work, even for right and left biliary ductal work! In this situation, no modifier is needed, since there are two procedures via different orifices/different families of codes. You could add –51 to the EGD code and list it second, as the lesser valued service. Medicare and other payors should reimburse at 50% of the usual allowance.

A. Since there is no code that accurately describes EGD with decompression, an unlisted UGI endoscopy code (43999) would be most appropriate, enclosing a procedure report which should make clear what time was required and what the relative work was by comparing it to an existing valued EGD code.

A. Yes. Code 43246 should be used with either modifier 62 or modifier 80. Check with the other physician to ensure both offices bill the same code with modifier 62 or to determine which physician is to bill as the assistant if that approach is used. Medicare recognizes 62 in this situation and reimburses both physicians at ½ of 125 percent of the usual allowance. Modifier 80 surgical assistant approach (recognized by some payers but not by Medicare for 43246) would typically pay the primary proceduralist 100 percent of the usual allowance and the assistant 16-20%; but there are few payers which would allow for an assistant in this procedure. Note that Medicare does NOT recognize two gastroenterologists reporting 43246-62 — only two different specialists. ASGE has appealed this policy.

(For more information on this subject, see Chapter 11 in Coding Primer: A Guide for Gastroenterologists, 2009)

A. Code 44373 would be the appropriate code to use to report this service. See Primer for detailed discussion of tubes that might be applicable. Radiologists utilize different codes to report the procedure using fluoroscopy. There is a code which sounds related, 43761, with descriptor “Repositioning of the gastric feeding tube, through the duodenum for enteric nutrition”, but presently it is a code without clarity as to how this would be used, and it is not valued as an endoscopic service; in theory it could be reported with an older 76000 fluoroscopy code if the gastroenterologist did the fluoro service and included a separate report for it.

However, there is a newer code that describes tube repositioning using fluoroscopy, typically reported by radiologists:

49446 - Conversion of gastrostomy tube to gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report.

A. In this case, the billing department of the hospital most likely billed the 76000 for the radiologist's services. This would preclude your office from using modifier -26. If the radiologist was not involved during the procedure, then the hospital’s billing for this is erroneous, and if they communicated their error to the payor, you could then bill 76000-26, assuming you prepared a report describing the work and findings. Radiologists are not supposed to bill Medicare for “over-reads” which are primarily for quality purposes, but if they assist you at fluoroscopy and provide a report of their service, they and not you can bill for the service.

A. A bedside placement by the physician of an NG feeding tube has no specific CPT code and would be reported with an E&M service to include whatever other E&M services were provided the same day. A tube placement requiring physician skill but requiring fluoroscopy can be reported as of 2008 as:

43752 - Naso- or oro-gastric tube placement, requiring physician's skill and fluoroscopic guidance (includes fluoroscopy, image documentation and report).

Code 91105 is not appropriate for feeding tube placement; it describes:

91105 - Gastric intubation, and aspiration or lavage for treatment (e.g., for ingested poison). Endoscopic gastrostomy placement is reported 43246.

A. If the tube is not being replaced, there is no specific procedure code and it is reported during an E&M face-to-face visit. If NO E&M service is provided at all and the physician placed the G tube himself, no service would be reported. However, if the G-tube was removed and replaced, code 43760 has a redefined meaning as of 2008:

43760 - Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance.

For endoscopic placement of gastrostomy tube, use 43246.

A. Not specifically under a drainage tube removal code. The drain tube removal is reported using an appropriate E&M service code.

A. Although an unusual combination, the answer is that yes, both procedures could be billed, but bundling edit software might lead to a denial of the 2nd code, and an appeal would be required, which depending on the payer and circumstances may or may not work. Code the endoscopy with dilation code first; whether 43249 (EGD) or 43220 (esophagoscopy, balloon dilation (less than 30 mm)) as appropriate (see Primer Chapter 4 for further details); the second code would be 43450, for bougie dilation, coded once regardless of number of dilators passed. Most typically, one endoscopic dilation code for wire-guided dilation would be used since the typical Savary type dilators are equivalent to the Maloney bougie (code choices then 43226 for esophagoscopy code; 43248 for EGD code). Another uncommon combination that might be billed is EGD with wire-guided dilation and a separate procedure with balloon dilator; for example using a balloon to do initial dilation of a tight asymmetric stricture, within a longer smoother stricture, then perhaps using the Savary type dilator over a guidewire to dilate the entire segment.

For Medicare, the NCCI edits indicate that code pair 43248/43450 could be billed if both procedures were medically necessary; yet 43249/43450 could not be billed together, the 43450 will not pass the edit even with modifier 59 added.

(For more information on this subject, see Chapter 12 in Coding Primer: A Guide for Gastroenterologists, 2009)

A. Code 43271 should be used to report the ERCP with the balloon dilation, and code 43262 should be used to report the sphincterotomy. These codes are not bundled, but they are part of the same endoscopic family, so some payers reject the second code. However, CPT language specifically says to report the sphincterotomy with 43262; and iCCI (NCCI?) edits do not require a 59 modifier (“distinct procedural service”) on the 2nd code. Some private payers may recognize the second service without need to appeal if modifier 59 is attached, so get to know the individual larger payers you deal with. Medicare contractors would pay the full amount on 43271 and for 43262 would pay the difference between 43262 usual allowance and the allowance for the base diagnostic ERCP code 43260. For private payers, you should be able to use modifier 51 and may receive the multiple surgery reduction of 50 percent on the second code; or the payer may follow Medicare convention. If they deny the 2nd code billed with –51 as if you were unbundling, resubmit with appeal letter and indicate that –59 modifier applied, enclose a report that shows you did both procedures and shows medical necessity and separate resource consumption for both.

(For more information on this subject, see Chapter 7 in Coding Primer: A Guide for Gastroenterologists, 2009)

A. Use code 43268, ERCP with endoscopic retrograde insertion of stent into bile or pancreatic duct. However, if a sphincterotomy was required and was performed the same day in order to place the stent, 43262 should be billed as the 2nd (lesser valued) procedure, with –59 for Medicare and either –51 or –59 or both for commercial payors.

A. A consultation can be provided for a new patient or an individual previously seen, if the service meets the requirements for consultation, so “new” isn’t a key concept here; however, CPT recognizes only one consultation per admission in the inpatient setting, other services being subsequent hospital care. If the consultation assessment led to the conclusion that an endoscopic procedure was needed same day, the procedure would be billed without modifier, and the E&M visit with the –25 modifier indicating “separately identifiable E&M service.” Some non-Medicare payers still do not recognize the E&M service, which should be appealed; and still can be charged to the patient. .Most of the largest national payers have settled class action suits brought by state medical societies in which they have agreed to abide by recognized CPT coding and CMS payment conventions. Let ASGE know when you’ve encountered payers who don’t appear to be playing by the rules we expect so we can investigate and advocate for change!

Rules are different for non-GI 10 and 90 global day services.

Note that if the procedure was planned and the evaluation was just to assess stability for the procedure or provide the administratively required H&P for a facility, no separately identifiable E&M service has been provided, since procedures have an element of E&M work also.

(For more information on this subject, see Chapter 14 in Coding Primer: A Guide for Gastroenterologists, 2009)

A. A consult is done when a physician “or other appropriate source” (defined in CPT consultation instructions) asks another doctor for his or her advice or opinion, and a report is sent back by the physician providing the evaluation. This doesn’t preclude ordering diagnostic tests or performing therapeutic procedures the same day as the evaluation, the procedures being separately reportable. In this situation commonly the –25 modifier is required on the consultation code so the E&M service isn’t regarded as incidental to or bundled with the therapeutic procedure.

If a physician refers a patient to you but has no intent to seek advice or opinion—and you have no medical need (apart perhaps from courtesy) to send a complete note in return, then the service is a new patient evaluation (e.g. 99201-99205 in the outpatient setting). Similarly, if the patient is self-referred or referred by family, the service is not a consultation, even if you send a letter to the patient’s primary physician.

A. Medicare rules and CPT language allow you to bill for 1 unit of service, regardless of the number of specimens tested in house or the number of cards given to the patient for home specimen collection. 82270 refers to the guaiac method on “consecutive collected specimens with single determination” and specifies it is for colorectal neoplasm screening, also specifically indicating that a set of 3 cards is involved. Thus this code would NOT be used for a fecal occult blood test performed during digital rectal exam. Instead, 82272 was amended in 2008 to describe 1-3 determinations for “other than colorectal neoplasm screening,” and is not specific about a method of cards—thus would be the code to report a diagnostic test from a digital rectal exam. Note also there is a separate code, 82274, for the fecal hemoglobin immunoassay determination, but this also applies to “1-3 simultaneous determinations.”

A. During colonoscopy, the code 43281 describes “directed submucosal injection(s), any substance” and would be the applicable code for India ink marking; but also for saline lift during polypectomy.