Gastroenterology Coding Alert

Question: I have been presented with an endoscopic hiatal-hernia repair. Which CPT codes should I use to report this?

Delaware Subscriber  
Answer: CPT has no specific code for the endoscopic repair of a hiatal hernia. Two new techniques, the Stretta procedure and endoluminal gastroplication, are often used by gastroenterologists to treat hiatal hernias and a related condition, gastroesophageal reflux disease.
  
The Stretta procedure uses radiofrequency energy delivered through needles to destroy nerves in the lower esophageal sphincter and cardia. An upper gastrointestinal endoscopy is first performed, the scope is removed, and an endoscopic catheter with a balloon tip is inserted into the patient. The balloon is inflated, and the needles delivering the radiofrequency energy are deployed.
 
The following codes are used to report the Stretta procedure, according to Karin Bolinger, director of reimbursement for Curon Medical Inc. in Sunnyvale, Calif.
 
43258 (upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with ablation of tumor[s], polyp[s], or other lesion[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique) should be used to report the upper gastrointestinal endoscopy.
 
64640 (destruction by neurolytic agent; other peripheral nerve or branch) should be used to report the destruction of nerves in the lower esophageal sphincter.
 
64640 should also be reported a second time to report the destruction of nerves in the cardia. Modifier -51 may be attached to this second listing of the code to indicate that multiple procedures were performed during the same operative session.
 
99141 (sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation) may also be billed to private payers. However, this code should NOT be reported to Medicare carriers, which have bundled this service into all endoscopy codes and will not reimburse separately for it. In fact, it may be considered fraudulent to bill a Medicare carrier for conscious sedation.  
The other technique, endoluminal gastroplication (ELGP), uses an endoscope with a suturing device at the end, which creates pleats in the lower esophageal sphincter muscles. The pleats tighten up the sphincter, which has been weakened by the hiatal hernia, and prevent reflux from flowing back into the esophagus. While the procedure may be assigned an emerging-technologies tracking code in the 2002 CPT, unlisted-procedure code 43499 (unlisted procedure, esophagus) should be used to report this procedure.
 
Since these are both new techniques, gastroenterologists should precertify the procedures with their payers to clarify the reimbursement.