Gastroenterology Coding Alert

Gastroenterology practices that bill separately for services that are commonly performed during an endoscopic ultrasound examination (EUS), such as Doppler studies or a celiac nerve block, may be able to boost their payout for the procedure from 10 to 30 percent. This may help combat the lower reimbursement that some gastroenterologists experienced when new EUS codes were added to CPT 2001.
 
For some procedures,  additional EUS codes have made it easier for a gastroenterologist to get appropriate reimbursement. "With a procedure like a rectal EUS, it's a huge advantage to have a specific code," says Lawrence Kim, MD, a gastroenterologist in Englewood, Colo., and a member of the American Gastroenterological Association's Committee on Practice Management and Economics. "Before, we used to bill this as just a diagnostic flexible sigmoidoscopy (45330). Now we get much better reimbursement."
 
The new EUS-guided fine-needle-aspiration codes (FNA), however, were assigned relative value units (RVUs) that were not much higher than the basic EUS examination. CPT 2001's prohibition of reporting radiology code 76975 (gastrointestinal endoscopic ultrasound, supervision and interpretation) with all of the FNA codes meant that in certain situations gastroenterologists would get paid less for performing the additional FNA procedure than if they had performed only the basic EUS examination.
 
An upper gastrointestinal endoscopy (EGD) with EUS (43259), for example, has a Medicare reimbursement of about $298 on an unadjusted basis. The radiological supervision and interpretation code 76975 can also be reported with 43259, which will add another $43. Total payment by Medicare for the procedure will be about $341.
 
On the other hand, when an FNA is performed during the EUS session, the level of reimbursement drops. Code 43242 is used to report the EGD with EUS/FNA, which pays about $299 from Medicare on an unadjusted basis. Unlike 43259, CPT 2001 prohibits billing 76975 with the FNA procedure. Unless other services are billed with the EUS/FNA, the total reimbursement from Medicare will be only $299.
 
This new reimbursement scheme coupled with the fact that an EUS can take much longer and is often riskier than other more highly valued endoscopic procedures leaves many gastroenterologists feeling underpaid. "In my opinion, we will never be reimbursed for an adequate amount for an EUS/FNA, since Medicare and other third-party payers have no clue as to how complex this procedure really is," says Roy Ligresti, MD, director of endoscopic ultrasound at New York Medical College in Valhalla, N.Y.

Reporting Codes for Diagnostic EUS
The first step to ensuring the most reimbursement for these procedures is to use the appropriate EUS code. The basic EUS is reported with three codes:
 
An esophagoscopy with EUS is reported with 43231. This code should only be used in the rare situation of [...]