Gastroenterology Coding Alert

Because no CPT code exists for injections of substances into the esophagus, except for sclerotherapy of esophageal varices, you should use an unlisted-procedure code to report Botox injections for treatment of achalasia, unless your payer's local medical review policy (LMRP) instructs otherwise. 43243 Is Inappropriate Although some coders and LMRPs advise assigning 43243 (Upper gastrointestinal endoscopy ; with injection sclerosis of esophageal and/or gastric varices) for Botox treatments, the code refers to injecting a hardening (sclerosing) solution into the veins at the end of the esophagus. "The code is essentially correct, but [it] describes treatment of the varices," says Glenn Littenberg, MD, FACP, a gastroenterologist in Pasadena, Calif., and a member of the AMA CPT editorial panel. Because Botox injections are usually injected into the lower esophageal sphincter, rather than the veins, 43243 does not accurately describe the procedure. Choose From Three Unlisted-Procedure Codes For Botox injections to treat achalasia, carriers recommend using unlisted-procedure/service codes:

20999 Unlisted procedure, musculoskeletal system, general 43499 Unlisted procedure, esophagus 90799 Unlisted therapeutic, prophylactic or diagnostic injection. HGSAdministrators' LMRP for Pennsylvania instructs coders to assign 20999 "when injecting Botulinum Toxin Type A into muscles that are not identified with their own HCPCS code and [to] give a description of the procedure performed." Note: For more on requirements for reporting Botox, see article 2. Blue Cross & Blue Shield (BC/BS) of Georgia's Medicare Part A LMRP recommends using 43499 for 530.0 (Achalasia and cardiospasm). Several LMRPs specify reporting 90799, including: AdminiStar Federal, Kentucky and Indiana's Medicare carrier Noridian, Iowa's Medicare Part B carrier Trispan Health Services, Mississippi's Medicare Part A BC/BS carrier. Include Documentation to Obtain Reimbursement Because the Medicare Fee Schedule does not assign relative value units for unlisted-procedure (UP) codes, you must include additional documentation to help the carrier determine appropriate reimbursement. When filing a claim with a UP code, you should include a letter in layman's terms describing the procedure performed and the doctor's service. You should also compare the UP code to an existing code. Littenberg suggests comparing 20999 and 43499 to 43243.

For example, a letter regarding an esophagogastroduo-denoscopy (EGD) performed to administer Botox injections on a Medicare patient in Georgia may read: Because no CPT code exists for the physician's services, I am using unlisted-procedure code 43499 (Unlisted procedure, esophagus). Although the work involved in this procedure is similar to 43243 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with injection sclerosis of esophageal and/or gastric varices), the physician injected the esophageal sphincter, rather than the varices. The service required about the same amount of time and risk. 90799 Is Fraught With Difficulties If the above scenario occurs in Indiana, you should report the [...]