Gastroenterology Coding Alert

Coding for a new procedure can be a bad dream. Ensure correct coding for M2A wireless capsule enteroscopy by getting a good handle on what the procedure does and how you can code for it.

M2A is a relatively new technology that has been in use in the U.S. in recent months for detecting small bowel abnormalities. Cleared by the FDA in August 2001, it provides noninvasive endoscopic testing. However, with this new procedure has come a variety of coding regulations, a temporary Medicare code, and varied acceptance by private payers.

The procedure includes three components: the M2A disposable imaging capsule, an external data recorder, and a computer that stores, interprets, and analyzes the data. The capsule helps detect abnormalities in the small intestine, such as Crohn's disease, celiac disease, intestinal tumors, and malabsorption. The unsedated patient swallows the capsule, and peristalsis moves it through the GI tract to the distal ileum. The capsule contains a lens, illuminating light-emitting diodes (LEDs), an energy source system, and a transmitter. The capsule transmits data through antennas placed on the patient's abdomen to a receiving unit worn around the patient's waist. At the test conclusion, the physician downloads the data to a computer to view, edit, and archive the test images. Physician involvement is estimated at 1.5 hours.

CMS has assigned a temporary code, G0262 (Small intestinal imaging; intraluminal, from ligament of treitz to the ileo cecal valve, includes physician interpretation and report), that you should use for all Medicare claims. For supplying the capsule, use code A4649 (Surgical supply; miscellaneous) for non-Medicare carriers, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C.

G0262 includes a professional component and a technical component, Weinstein says. The professional component includes the physician interpretation or reading of the capsule video images. The technical component includes the cost of the capsule and associated service in attaching the antenna to the patient and retrieving the recorder from the patient. If the test is provided at a hospital, the physician should bill for the professional component using code G0262 with modifier -26, and the hospital will bill for the technical component using G0262 with modifier -TC. If the service is provided by the physician from his office, the service is billed using the code without a modifier.

Note, however, that Medicare coverage for M2A capsule endoscopy varies by local carrier and payment varies by region, so it is vital that you check your local medical review policy (LMRP), says Pat Stout, CMT, CPC, president, Onesource Billing, in Knoxville, Tenn. You can find the policy listed under "Wireless capsule enteroscopy." For example, a quick check of two carriers' policies (Noridian Administrative Services in Colorado and HGSAdministrators in Pennsylvania) revealed how indications and limitations of coverage and/or medical necessity differ by carrier. HGSAdministrators covers the test for patients with small bowel neoplasms or Crohn's disease (both under certain conditions, such as the patient being symptomatic for the condition), whereas Noridian does not.

Non-Medicare payers are another story. When you deal with commercial payers, Stout says, getting paid is like a "moving target" because of policy variations. Private payers vary in their coding requirements; some may still consider the test investigational or experimental and therefore not reimbursable. Some accept code G0262; others require another code.