Gastroenterology Coding Alert

Question: Our gastroenterologist performed endoscopic tissue marking with the assistance of a clip. Which code describes the service?

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Answer: When your gastroenterologist uses a clip for endoscopic tissue marking, you won’t find any specific CPT^® codes for this service. You will have to use an unlisted-procedure code such as 43499 (Unlisted procedure, esophagus), 44799 (Unlisted procedure, intestine), or 45399 (Unlisted procedure, colon) depending on the area where the physician places the clip.

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.

What to do:  You should submit full documentation with every unlisted-procedure claim. To improve your reimbursement chances, you should include these documents, whenever possible:

• Show a calculation of your charges for 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. Be prepared to accept less than 100 percent of your billed amount from the payer.
• Give a detailed description of the procedure performed by your gastroenterologist and skip overt medical jargon and confusing terminology.
• For enforcing your claim, include some comparison with procedures that have an existing CPT^® code that requires similar work and resources. This may get better traction with the insurer while deciding the claim. Including an invoice for a device such as a clip can support the practice expense for facility billing.