Gastroenterology Coding Alert

Don’t forget to factor in descriptor changes to cover route of scope introduction.

When your gastroenterologist performs an esophagoscopy using a rigid scope in 2014, you’ll have to scour through a new code set for rigid esophagoscopies to accurately report the procedure – you also have to factor in more new codes that have been added to flexible endoscopies, upper EGD procedures and ERCPs.

(For an overview of the CPT® 2014 changes, see Gastroenterology Coding Alert Vol. 15, No. 10).

Use Separate Code Set for Esophagoscopy Using Rigid Scope

We had told you in the earlier issue that you will have descriptor changes to the currently used code range 43200-43232 (Esophagoscopy, rigid or flexible…) to remove the word “rigid” from the descriptor and making this range specific for esophagoscopy procedures employing a flexible scope.

“Esophagoscopy with rigid instruments have become rare and tend to be done by surgeons,” says Michael Weinstein, MD, Gastroenterologist at Capital Digestive Care in Washington, D.C., and former representative of the AMA’s CPT® Advisory Panel. But if one of your physicians does perform a rigid esophagoscopy then you’ll have to use the following six-code set that will be introduced in 2014:

• 43191 (Esophagoscopy, rigid, transoral; diagnostic, including collection of specimen[s] by brushing or washing when performed [separate procedure])
• 43192 (…with directed submucosal injection[s], any substance)
• 43193 (…with biopsy, single or multiple)
• 43194 (…with removal of foreign body)
• 43195 (…with balloon dilation [less than 30 mm diameter])
• 43196 (…with insertion of guide wire followed by dilation over guide wire)

Coding example: Your gastroenterologist reviewed a patient with symptoms of dysphagia and reflux. He introduces a rigid scope through the mouth and reaches the esophagus where he observes a stricture. He then introduces and performs balloon dilation. If the date of service is before Jan.1, 2014, you will report this with 43220 (Esophagoscopy, rigid or flexible; with balloon dilation [less than 30 mm diameter]). However, if the date of service is after Jan.1, you’ll have to use 43195 to report the procedure as you’ll have to report a procedure with a rigid scope using different code sets.

In addition, CPT® 2014 will see the addition of two new codes that can be used when your gastroenterologist performs an esophagoscopy using a flexible scope that is inserted through the nose. “Technological advances have produced small diameter video endoscopes that can be safely and comfortably introduced through the nose to examine the pharynx and upper GI tract down to the duodenum,” adds Weinstein. So, the two new codes that you will need to be aware of to use for an esophagoscopy employing a flexible scope introduced via an intranasal route include:

• 43197 (Esophagoscopy, flexible, transnasal; diagnostic, including collection of specimen[s] by brushing or washing when performed [separate procedure])
• 43198 (…with biopsy, single or multiple)

Watch For New Code Additions to Esophagoscopy and Upper EGDs

In addition to descriptor changes to the existing code range to describe an esophagoscopy procedure to exclude the word “rigid” and to introduce the word “transoral” to describe that the scope was introduced using an oral route, you’ll also be required to use some new codes for endoscopic mucosal resection (often abbreviated as EMR but not to be confused with electronic medical record), dilation, ablation and stent placements.

So, the new codes that you need to capture for these procedures will include the following:

• 43211 (Esophagoscopy, flexible, transoral; with endoscopic mucosal resection)
• 43212 (…with placement of endoscopic stent [includes pre- and post-dilation and guide wire passage, when performed])
• 43213 (…with dilation of esophagus, by balloon or dilator, retrograde [includes fluoroscopic guidance, when performed])
• 43214 (…with dilation of esophagus with balloon [30 mm diameter or larger] [includes fluoroscopic guidance, when performed])
• 43229 (…with ablation of tumor[s], polyp[s], or other lesion[s] [includes pre- and post-dilation and guide wire passage, when performed])

Example: Your gastroenterologist assesses a patient with GERD who is not responding to previously prescribed proton pump inhibitors. Your clinician introduces a flexible scope to observe the GI tract and encounters a stricture in the esophagus. He uses a dilator to overcome the stricture and then places a stent to prevent collapse of the tract and recurrence of the stricture.

If the service was performed in 2013, you’d have reported it with 43219 (Esophagoscopy, rigid or flexible; with insertion of plastic tube or stent). You will have to report the dilation procedure with 43220. However, if the service is performed after Jan.1, 2014, you will have to report this with 43212. As you can see from the descriptor to the code, the dilation is included within the same code. So, you will not report it separately as you would do in 2013.

Upper EGDs: Similarly, in addition, to descriptor changes to upper EGD procedures, you’ll see the introduction of some new codes in the code range of 43235-43273, which describe endoscopic mucosal resection, stent placements, dilation, ablation, and fiducial marker placement. “Fiducial markers have been integrated into the management of multiple malignancies to guide more precise delivery of radiation therapy (RT),” reminds Weinstein.

• 43233 (Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon [30 mm diameter or larger] [includes fluoroscopic guidance, when performed])
• 43253 (…with transendoscopic ultrasound-guided transmural injection of diagnostic or therapeutic substance[s] [e.g., anesthetic, neurolytic agent] or fiducial marker[s] [includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis])

Add New Codes to These ERCP Procedures

While you have to incorporate some descriptor changes to the old ERCP codes, you’ll also have to delete some old codes from your earlier ERCP code sets (see GAC Vol. 15, No. 10.) and add some new ones. Again, as in esophagoscopy and upper EGD procedures, you will have new codes to describe dilations, stent placements and ablation.

The new codes that you have to add to your ERCP code lists will include:

• 43274 (Endoscopic retrograde cholangiopancreatography [ERCP]; with placement of endoscopic stent into biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent)
• 43275 (…with removal of foreign body[s] or stent[s] from biliary/pancreatic duct[s])
• 43276 (…with removal and exchange of stent[s], biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent exchanged)
• 43277 (…with trans-endoscopic balloon dilation of biliary/pancreatic duct[s] or of ampulla [sphincteroplasty], including sphincterotomy, when performed, each duct)
• 43278 (…with ablation of tumor[s], polyp[s], or other lesion[s] [includes pre- and post-dilation and guide wire passage, when performed])

Keep in mind: Until the annual publication of the CPT® code set, small further revisions may occur to the 2014 codes. Keep an eye on further issues of the Gastroenterology Coding Alert for additional news on these new codes.