Gastroenterology Coding Alert

Question: Our gastroenterologist performed photodynamic therapy (PDT) for one hour on a patient with Barrett's esophagus. We reported 96567 (Photodynamic therapy by external application of light to destroy premalignant and/or malignant lesions of the skin and adjacent mucosa [e.g., lip] by activation of photosensitive drug[s], each phototherapy exposure session) and were denied. What did we do wrong?

Connecticut Subscriber

Answer: Simply put, you used the wrong PDT code. As its explanation indicates, code 96567 is for external PDT, and the PDT the gastro performed was endoscopic, meaning you should not report an external PDT code.

When a gastro administers PDT, the PDT is given endoscopically, and you should file a claim with a minimum of two codes: one for endoscopy and (at least) one for the illumination of the cancerous cells in the patient.

If your gastroenterologist performs one hour of PDT on a patient, you should:

 report 43228 (Esophagoscopy, rigid or flexible; with ablation of tumor[s], polyp[s], or other lesions[s], not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique) for the endoscopy. (Note: In some cases, you can use  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].)

 attach ICD-9 code 530.85 (Barrett's esophagus) to 43228.

 report +96570 (Photodynamic therapy by endoscopic application of light to ablate abnormal tissue via activation of photosensitive drug[s]; first 30 minutes [list separately in addition to code for endoscopy or bronchoscopy procedures of lung and esophagus]) for the first half-hour of light application.

 report +96571 x 2 (... each additional 15 minutes [list separately in addition to code for endoscopy or bronchoscopy procedures of lung and esophagus]) for the second half-hour of light application. Remember: Since these are add-on codes, you do not need to report any modifiers.