General Surgery Coding Alert

Accommodate double standards based on payer.

Maybe you’re thrilled that CPT® 2015 provides you with more than 20 new codes to accurately describe your surgeon’s lower gastro-intestinal endoscope procedures such as colonoscopies, sigmoidoscopies, and anoscopies.

But don’t get too excited about reporting those codes — to Medicare, anyway — unless you don’t want get paid for your surgeon’s work.

Don’t worry: We have a handy tool for you to make sure you get paid for lower GI endoscopies in 2015, no matter who the payer is.

Learn CMS’s Problem and Solution

Medicare lists the new CPT® 2015 lower GI endoscopy codes in the Physician Fee Schedule (PFS) with an ‘‘I’’ (Not valid for Medicare purposes) for calendar year 2015.

According to the PFS final rule (available in the Nov. 13, 2014 Federal Register), commentators and CMS agreed that pricing the new codes should wait until 2016 “in light of the substantial nature of this code revision and its relationship to the policies on moderate sedation [which are under valuation review].” Instead, CMS plans to hold pricing for these services steady at 2014 levels.

Problem: You can’t keep reporting the procedures to Medicare as you did in 2014, because CPT® 2015 revises or deletes many of the existing lower GI endoscopy codes.

Solution: CMS provides 10 new HCPCS Level II codes that you should use to report these services to Medicare, instead of using the new CPT® 2015 lower GI endoscopy codes.

Take These Steps for 2015 Medicare Reporting

“Unfortunately, the CMS solution is not that simple to implement,” cautions Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CCC, COBC, CPC-I, internal audit manager at PeaceHealth in Vancouver, Wash.

“To bill Medicare, you would first have to code the procedure as you would have done in 2014 — remember that many of these codes are deleted, so they might not be in your system anymore,” she says. “Then, you would have to crosswalk the 2014 coding to the appropriate ‘G’ code for Medicare.”

More confusion: At the same time that you’re trying to implement this alternative coding scheme for Medicare, your practice should be correctly coding the same procedures using the new CPT® 2015 lower GI endoscopy codes.

Let us help: Table 1 links all the pertinent data in one place to make your job easier. Use the table and the following easy steps as a handy tool to make sure you select the proper code:

• To select the proper lower GI endoscopy code for non-Medicare payers in 2015, simply match the brief code descriptor in the second column with the new CPT® 2015 code in the first column — that’s your code for non-Medicare payers.
• To select the proper lower GI endoscopy code for Medicare payers in 2015, use the table as you did for non-Medicare payers, but then, look to the fourth column containing mostly G codes — that’s your code for Medicare payers.
• CMS priced the G codes on the PFS using the 2014 crosswalk code value, according to Joel V. Brill, MD,FACP, AGAF, AMA CPT® advisory committee member, in his presentation at the CPT® and RBRVS 2015 Annual Symposium. Notice that G codes crosswalked from unlisted code 44799, as well as the anoscopy G codes, are carrier priced and don’t appear with a value on the PFS.

Double check: If you want to check yourself based on how you would have coded the procedures in 2014, you can look at the third column in the table.

Final caution: “Although Medicare did not price these new CPT® 2015 codes on the PFS, they did price them as part of the outpatient prospective payment system (OPPS). That means if you bill the physician side and the facility side for these procedures, you’ll have to switch up your coding, even for the same Medicare payer,” Bucknam says.