Part B Insider (Multispecialty) Coding Alert

Published on Mon May 26, 2014 PDF

Hint: Watch for CCI bundling for multiple procedures involving other tumor removal methods.

When your clinician performs an ablation of a tumor or a polyp, you need to factor in the extent to which your clinician visualized the GI tract and know what other procedures your gastroenterologist performed in the same session. Watch out for edit bundles as this might lead to incomplete payment of claims.

Opt From Esophagoscopy or EGD Codes Depending on Extent of Scope

If your gastroenterologist performed an ablation to destroy a tumor or a poly, you will need to look at the extent to which your gastroenterologist visualized the upper GI tract using the endoscope to land the right code to report the procedure. 

If your clinician performed an ablation and did not extend the scope beyond the esophagus, then you need to report the procedure using 43229 (Esophagoscopy, flexible, transoral; with ablation of tumor[s], polyp[s], or other lesion[s] [includes pre- and post-dilation and guide wire passage, when performed]). If your gastroenterologist visualized the areas of the stomach and beyond the pyloric channel into the duodenum and/or the jejunum, then you need to report the procedure using the code 43270 (Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor[s], polyp[s], or other lesion[s] [includes pre- and post-dilation and guide wire passage, when performed]).

Heads up: When your gastroenterologist performs esophagoscopic photodynamic therapy (PDT), you will have to report this procedure with either of the add-on codes, +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 gastrointestinal tract]) or +96571 (…each additional 15 minutes...) along with 43229. 

Note that +96570 and +96571 are selected based on time spent on performing PDT. For 23-37 minutes of service, use 96570. For 38-52 minutes of service, use 96570 in conjunction with 96571.

Don’t Report Dilation and Guide Wire Use Separately

If you look at the code descriptors to the ablation codes, 43229 and 43270, you will notice that it mentions the phrase “includes pre- and post-dilation and guide wire passage, when performed.” This informs you that if your clinician had to overcome any obstruction or stricture by use of guide wire or dilators, you cannot report these procedures separately with 43229 and 43270.

Coding example: Your gastroenterologist performs an upper EGD for a patient suffering from dysphagia, severe abdominal pain and bloating. When performing the procedure, your clinician encounters a stricture in the gastroesophageal junction that does not allow your clinician to extend the scope further. 

Your clinician then introduces a guide wire over which he passes over a dilator and dilates the stricture to allow the scope to pass through. He then examines the stomach, duodenum and jejunum. During the examination, he encounters two polyps in the duodenum that he ablates. 

What to report: Since your clinician passed the scope to the stomach and beyond and then performed an ablation, you will report the procedure with 43270. Since the guide wire insertion and dilation is included in the work described by 43270, you will not report 43248 (Esophagogastroduodenoscopy…with insertion of guide wire followed by passage of dilator[s] over guide wire) separately.

Exercise Caution When Reporting Ablation With Other EGD Procedures

Your clinician might perform multiple EGD procedures in the same session. When your clinician performs such multiple procedures, multiple endoscopic payment rules will apply. If your clinician is performing other EGD procedures in the same session in which he performs an ablation, you will also need to pay attention to Correct Coding Initiative (CCI) edits.

Some of the EGD procedures that run into edits with 43270 include:

• 43250 (Esophagogastroduodenoscopy…with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery)
• 43251 (…with removal of tumor[s], polyp[s], or other lesion[s] by snare technique)
• 43254 (…with endoscopic mucosal resection)
• 43255 (…with control of bleeding, any method)

All the above mentioned edits carry a modifier indicator of ‘1,’ which means that you can unbundle the codes with the use of a suitable modifier such as 59 (Distinct procedural service). So, if for example, your clinician performs removal of a polyp by ablation and removal of another polyp by snare technique, you can report both 43251 and 43270. You will have to append modifier 59 to 43251.

Caveat: If your clinician performs an ablation of a tumor or polyp and during the procedure encounters bleeding and controls it with a plasma coagulator, then you cannot report 43255 for the bleeding control. You cannot do this as the bleeding control is part of the polyp removal procedure and so cannot be reported separately. But, if the polyp removal and the bleeding control were in two different sites, you can use the modifier to unbundle the codes and report them separately. Provide documentation supporting your claims when you do so.