General Surgery Coding Alert

Some payers also waver on virtual colonoscopy pay

If you're planning to report new-for-2005 codes for wound vacuum assisted closure (VAC), endoscopic treatment of gastroesophageal reflux disease (GERD) or virtual colonoscopy, you might want to check with your payer first. Providers are being reminded once again that just because CPT adds a code to describe a procedure, payers won't necessarily reimburse.

Don't Charge Separately for Wound Vac 

You won't be able to bill separately for VAC codes 97605 (Negative pressure wound therapy [e.g., vacuum assisted drainage collection], including topical application[s], wound assessment, and instruction[s] for ongoing care, per session; total wound[s] surface area less than or equal to 50 sq cm) and 97606 (... greater than 50 sq cm). CMS slapped these with status "B," meaning they're considered bundled with any other service you might provide (see General Surgery Coding Alert, February 2005, for more information).

Status B means a code is "never paid," says Collette Shrader with Wenatchee Valley Medical Center in Wenatchee, Wash. "They feel that the work that is involved in that code is paid under something else." For example, Medicare will never pay for conscious sedation because CMS believes the surgeon is already monitoring the patient's conscious sedation as part of the surgery.

Stretta Procedure Feels the Heat

Similarly, some payers are refusing coverage for the popular Stretta procedure, an endoscopic treatment for GERD. CPT introduced 43257 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease) this year, replacing Category III code 0057T.

Medicare payer Noridian has released a draft local coverage decision stating that it won't pay for 43257 under any circumstances. Specifically, the payer will consider the Stretta procedure "not yet proven effective" until more clinical data come in.

It's not surprising that carriers are cautious about covering the Stretta procedure, says one coding expert who declined to be quoted. The procedure remains controversial in the medical community because there are no data on long-term effects.

Carriers Don't Agree on Virtual Colonoscopy

The good news is that National Heritage Insurance Co. (NHIC) said it would follow the example of Empire Medicare Services in adding coverage for virtual colonoscopy 0066T (Computed tomographic [CT] colonography [i.e., virtual colonoscopy]; screening) and 0067T (...diagnostic) (see General Surgery Coding Alert, February 2005, for more information).

NHIC said it would only cover virtual colonoscopy in cases where an "instrument colonoscopy of the entire colon is incomplete." But NHIC won't consider virtual colonoscopy as an alternative when an instrument (or fiberoptic) colonoscopy is possible.

Noridian, however, has stated in a new draft LCD that it wouldn't cover virtual colonoscopy under any circumstances. Because peer-reviewed literature doesn't support the procedure's effectiveness, even if the physician is unable to complete a fiberoptic colonoscopy, Noridian won't reimburse a virtual colonoscopy.