Gastroenterology Coding Alert

Cut out unnecessary steps when reporting endoscopic marking clips

If your gastroenterologist uses clips to control bleeding during endoscopies or colonoscopies, you probably know that the clip application is an inherent part of the procedure. By isolating the procedure codes associated with clips, you-ll be on your way to creating a perfect claim every time.

First, Catch These Clip Basics

What they are: Clip devices are instruments designed to accomplish approximation of tissues. Gastroenterologists deliver one clip per loading and passage through an endoscope, for example. The gastroenterologist applies the clip with pressure onto the target tissue and closes it manually by squeezing the catheter handle assembly. They can use clips during various procedures, including colonoscopies, esophagoscopies and sigmoidoscopies.

Indications: Gastroenterologists typically use clips as hemostasis for mucosal/submucosal defects, bleeding ulcers, bleeding arteries 12 mm in size, polypectomy sites, and diverticula in the colon. For instance, -our doctor recently used a clip as opposed to cauterization for a polyp he removed that was oozing blood,- says Jane Viera, office manager at South County Gastroenterology in Narragansett, R.I.

Use 1: Capture These Control-of-Bleeding Codes

Gastroenterologists typically use clips as a control-of-bleeding or -hemostasis- technique. Therefore, when you spot clip application used to control bleeding in your claim, you will know to look at the following procedure codes:

- 43227--Esophagoscopy, rigid or flexible; with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
- 43255--Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with control of bleeding, any method
- 44366--Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with control of bleeding ...
- 44378--Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with control of bleeding ...
- 44391--Colonoscopy through stoma; with control of bleeding ...
- 45334--Sigmoidoscopy, flexible; with control of bleeding ...
- 45382--Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding ...

Example: Your gastroenterologist performed a video esophagogastroduodenoscopy (EGD) with small bowel enteroscopy, clipping and BICAP cautery as well as biopsies. The patient had a 2-mm bleeding arteriovenous malformation (AVM) in the fourth portion of the duodenum that the physician controlled by ablation with BICAP cautery and with a tri clip application. Also, the patient had a 1-mm AVM in the proximal jejunum that the gastroenterologist ablated with BICAP cautery.

Solution: Don't fall into the trap of thinking this example should include multiple codes. Because the gastroenterologist used all of these modalities to accomplish one goal--basically the AVMs- hemostasis/occlusion--you should use only one code (43255), says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel.

Use 2: Examine Endoscopic Marking Claims

If your gastroenterologist uses a clip for endoscopic tissue marking, you won't find any specific CPT codes for this service. The procedure defaults to an unlisted-procedure code for the area where the physician places the clip. Therefore, you-ll use 44799 (Unlisted procedure, intestine).

No standard fee exists for unlisted-procedure codes. Rather, payers consider claims on a case-by-case basis, so the success of any unlisted-procedure claim depends largely on the documentation you submit with your claim.

Best bet: You should submit full documentation with every unlisted-procedure claim. To improve your reimbursement chances, you should take three additional steps, whenever possible:

- Include a cover letter with a concise explanation of the procedure, free of medical jargon and confusing terminology.
- Compare the procedure to one with an existing CPT code that requires similar work and resources. This allows the payer to make an informed payment decision.
- Assign a charge to the unlisted-procedure code. Because unlisted-procedure codes do not have any associated payment, you must identify the amount of reimbursement you wish to be paid. Remember that the insurer may not reimburse 100 percent of your charge.

Use 3: Calculate These Closure Possibilities

If your gastroenterologist uses a clip as a closure method secondary to another procedure, then again, payers will consider the clip application inherent in the primary procedure.

But if the physician uses a clip during a separate event (such as placing a clip for closure of a perforation two days after a polypectomy), you can code this service separately--but only if the clipping is the only closure method the physician uses. Again, you-ll use an unlisted-procedure code (44799) for this procedure.

Bonus: You-ll find no separate code for anchoring a jejunal feeding tube using a clip. This service is inherent in the primary procedure coding for the tube attachment.