Take the Guesswork Out of Ambulatory Endoscopy Coding
Published on Sun Dec 01, 2002
Because coverage and coding guidelines for procedures performed in an ambulatory surgical center (ASC) differ from those performed in inpatient and other settings, you need to be clear on some common misunderstandings that abound regarding reimbursement for ambulatory procedures.
Gastroenterologists perform a variety of endoscopic procedures in ambulatory surgical centers. By following some simple rules, you can learn how to receive full benefits from endoscopies performed in ASCs and learn which procedures cannot be billed in this setting. Most Endoscopies Are Covered in ASCs According to the Medicare Carriers Manual, an ASC by definition is "a distinct entity that operates exclusively for the purpose of furnishing outpatient surgical services." These centers are either independent or operated by a hospital.
According to Stephanie Goodfellow, billing manager at Mid-America Gastro-Intestinal Consultants in Kansas City, Mo., her practice does almost all of the endoscopic procedures in the ASC setting, especially colonoscopies and upper gastrointestinal endoscopies (EGDs). She has not found it difficult to get reimbursed for these procedures. However, she warns others to be wary when filing for ambulatory services in a center that is owned by the doctor performing the surgery. She explains that their doctors "own the facility, but it is under a different name and tax ID number, and sometimes the insurance companies will get it confused as a duplicate." Of course there will be other problems if you bill for a procedure that is not on Medicare's approved list of ambulatory procedures.
There is a list of about two-dozen procedures that are not reimbursable if performed in an ambulatory setting. Take note of some that may directly affect your practice: Small intestine endoscopy series (44376-44379)
45300 Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen[s] by brushing or washing
45330 Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing
Anoscopy codes 46600-46606 and 46614-46615
+47550 Biliary endoscopy, intraoperative (choledochoscopy)
Many of the endoscopic procedure codes that include ultrasound techniques, such as 43242 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/ biopsy[s]) and 45341 (Sigmoidoscopy, flexible; with endoscopic ultrasound examination).
Many of the endoscopic procedures that include stent placement, such as 45387 (Colonoscopy ...; with transendoscopic stent placement [includes predilation]).
Many of the endoscopies that involve band ligation such as 43244 (Upper gastrointestinal endoscopy ...; with band ligation of esophageal and/or gastric varices). A few of these unlisted procedures may cause particular problems for gastroenterologists. Pat Stout, CMC, CPC, an independent gastroenterology coding consultant and president of OneSource, a medical billing company in Knoxville, Tenn., says the sigmoidoscopy (45330) is not approved to be performed in the ASC, but 45331 (Sigmoidoscopy, flexible; [...]
