Gastroenterology Coding Alert

In addition: Catch bundles affecting hemorrhoidectomy and paracentesis.

Hold your horses before you report evaluation and management services with gastroenterology procedures your physician performs. The latest Correct Coding Initiative (CCI) edits (version 19.2), effective July 1, includes a host of bundles that’ll scupper your claims if you’re billing E/M services with these common gastro procedures. 

Mammoth: In CCI version 19.2 “the number approaches 300,000, so this one is a whopper,” according to Frank Cohen, MPA, MBB, principal and senior analyst for The Frank Cohen Group in Clearwater, Fla. “For column 2 codes, E/M led the pack with almost 95% of the total, so we can expect the changes in this release to affect everyone.”

Check Modifier Indicator to Unbundle Codes

CCI 19.2 adds almost every gastroenterology procedure code that you normally use and bundles them with E/M services. Column 1 upper endoscopic and ERCP procedural codes 43200-43272; intubation and gastrostomy codes 43752-43761; small intestine endoscopy and colonoscopy through stoma codes 44360-44397; lower endoscopic codes 45300-45392; biliary endoscopic codes 47552-47556 and gastroenterology procedure codes 91010-91122 bundle all of the following column 2 codes:

• Office/outpatient and inpatient problem-oriented E/M codes (99211-99239)
• Consultation codes (99241-92255)
• Critical care codes (99291-99292)
• Nursing care codes (99304-99316)
• Domiciliary, rest home, or custodial (assisted living) care codes (99324-99337)
• Care plan oversight code (99374-99378)

Global background:  Minor procedures (those with 0- and 10-day global periods) may include a minor E/M service that was not “significant and separately identifiable.” Major procedures (with a 90-day global period) have always included any E/M services provided the day of and the day before the procedure.

“The inclusion of the E/M services have always been by definition part of the global period,” says Barbara J. Cobuzzi, MBA, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. “Now it seems that CCI wishes to include these included E/M services by virtue of specific listing as bundled pairs in addition to the global definitions.”

In general when a patient has an out-patient endoscopic procedure at a hospital out-patient department or ambulatory surgery center the regulation requires some documentation of a pre-procedure history & physician assessing the patient’s medical condition to safely undergo the procedure and receive medications for sedation.  “The pre-procedure evaluation on the date of the procedure is included in the work defined for each GI procedure and is not considered a separately identifiable service,” says Michael Weinstein, MD, Gastroenterologist at Capital Digestive Care in Washington, D.C., and former representative of the AMA’s CPT^® Advisory Panel.  “Nonetheless many offices have coded these pre-procedure services with E&M codes which will usually be denied.  The new CCI edits more explicitly bundles this service with the procedure.” 

The modifier indicator for all of these edits is “1.” That means you can override the bundling edits with the proper modifier in certain clinical scenarios. While the first modifier you’ll think of when talking about CCI edits is modifier 59 (Distinct procedural service), the modifiers most often used to break edits with E/M services will be modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service). The standard pre-procedure H&P would not constitute a significant and separate service. 

One example where it might be appropriate would be the patient seen for an upper endoscopy who coincidentally has a problem with rectal pain and bleeding on the date of the EGD procedure.  In this case the physician would take a history related to the rectal complaint, perform the appropriate examination of the region, and recommend treatment for the condition. 

Red flag: In addition to these above mentioned gastroenterology procedural codes, you should also take care to check bundling when you are thinking of reporting any screening procedures that your gastroenterologist performs with an E/M service. Some of the screening codes and other G codes that you’d normally use that are covered under CCI version 19.2 include the following:

• G0104 (Colorectal cancer screening; flexible sigmoidoscopy)
• G0105 (Colorectal cancer screening; colonoscopy on individual at high risk)
• G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk)
• G0455 (Preparation with instillation of fecal microbiota by any method, including assessment of donor specimen)

This bundle of E&M service and the G-codes for screening colonoscopy or sigmoidoscopy is true even when the E&M service is performed on a date before the procedure when the only reason for the E&M service is to discuss colorectal cancer screening options. 

Get a Handle on These Hemorrhoidectomy Bundles

When your gastroenterologist performs a hemorrhoidectomy, you will not be able to report any lower endoscopic procedural code with it, thanks to the edits included in the version 19.2 of the CCI. The edits specify that you cannot report 45300 (Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) or 45330 (Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) with the following hemorrhoidectomy codes:

• 46945 (Hemorrhoidectomy, internal, by ligation other than rubber band; single hemorrhoid column/group)
• 46946 (Hemorrhoidectomy, internal, by ligation other than rubber band; 2 or more hemorrhoid columns/groups)

Note: The modifier indicator for these above mentioned code bundles is ‘1,’ that indicates that a modifier such as 59 can be used to unbundle these codes. But, this should not be done on a routine basis and is warranted only when your clinician performs the endoscopic procedure to check for any additional lesions or bleeding issues. You will need to submit additional documentation to support the use of the modifier to unbundle the codes.

Check These Lavage and Paracentesis Procedural Bundles

If your gastroenterologist is performing an abdominal paracentesis and a peritoneal lavage, you cannot report the paracentesis procedure separately as per the CCI version 19.2 edits. So, you cannot report 49082 (Abdominal paracentesis [diagnostic or therapeutic]; without imaging guidance) or 49083 (Abdominal paracentesis [diagnostic or therapeutic]; with imaging guidance) if you are reporting 49084 (Peritoneal lavage, including imaging guidance, when performed) for the lavage. These edits indicate that the paracentesis is included in the “more extensive” lavage procedure. Also, the edits bundle 49082 and 49083, allowing you to only report 49083 as a more extensive procedure than 49082 which does not include any imaging guidance used during the procedure.

Caveat: These above mentioned edits carry the modifier indicator ‘0,’ which lets you know that you cannot unbundle these edits under any circumstances. So, you cannot report these two procedural codes when your gastroenterologist performs these two procedures together in the same session.