Gastroenterology Coding Alert

You cannot report 46221 (Hemorrhoidectomy, by simple ligature [e.g., rubber band]) separately from the following hemorrhoid codes:

These hemorrhoidectomy bundles will not affect coding substantially, Parks says. In current practice, physicians treat a hemorrhoid either by rubber-band technique (46221), which allows it to die off, or by removing the hemorrhoid (46230-46258) not both.

The bundling of the ECG and Doppler study shows that CMS feels that physicians need to provide some justification when they separately report these services on the same day, says Joe Brill, MD, a gastroenterologist in Phoenix who is the American Gastroenterological Association representative to the CPT Editorial Advisory Committee and RBRVS Update Committee.

Parks says her practice never bills separately for the ECG during the EGD because CMS includes it in the facility fee.

"The biggie" for this edition of NCCI, however, is the inclusion of the Doppler study with the fine needle aspiration (43242) and EUS (43259) codes, Parks says. These codes do not pay well considering the amount of work associated with them. The payment for the Doppler study (about $62 for the professional component) was an added incentive. Now, you will not be able to receive reimbursement for that portion of the procedure.

According to Brill, another big issue is the anesthesia bundling. CMS has become aware that in certain parts of the country, physicians unbundle 99141 (Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation) from endoscopic procedures. Conscious sedation, or monitored anesthesia, is inherent to the physician work of an endoscopy. However, in the Dec. 31, 2002, Federal Register, CMS stated that the work associated with conscious sedation is "zero."

CMS is also seeing a trend where physicians use a CRNA or anesthesiologist to administer monitored or deep anesthesia for the patient undergoing an endoscopy. If it is done for medical necessity, then that is acceptable. But if it is done for patient or physician convenience, CMS objects to the practice.

Another issue is what the physician should do when the patient requires anesthesia support. Should the endoscopist use a reduced-service modifier? These issues are rapidly coming to a head at CMS, Brill tells Gastroen-terology Coding Alert. Look for updates in the future.