Part B Insider (Multispecialty) Coding Alert

Published on Thu Aug 07, 2003 PDF

Bill Two Biopsies on the Same Day

 
If you're frustrated by new restrictions on what you can bill for with an endoscopic ultrasound, then you should enjoy the coding possibilities you still have. It could have been much worse.
 
Version 9.1 of the National Correct Coding Initiative, which took effect April 1, nixed several add-on procedures that gastroenterologists had been accustomed to billing with endoscopic ultrasound (EUS) procedures. In particular, the NCCI Edits put paid to billing for 76942, for needle guidance supervision and interpretation, with EUS codes 43232, 43242 and 45342.
 
But not all of the edits that the Centers for Medicare & Medicaid Services had proposed for the April NCCI update actually went into effect. CMS had proposed to create edits that would have prevented billing for standard endoscopic biopsy with codes 43231, 43232, 43242, 45341 and 45342, for EUS with or without fine needle aspiration biopsy. The American Society for Gastrointestinal Endoscopy, the American Gastroenterological Association, and the American College of Gastroenterology protested these proposed edits.
 
The three societies pointed out that the two procedures are very different and involve different techniques. They cited an example: A patient with a pancreas head mass turns out to have an intraluminal mass lesion in the stomach that hadn't been detected previously. Since a second malignancy would "significantly alter treatment plans," the physician performs an EUS with FNA of the pancreas mass (43242) and a standard endoscopic forceps biopsy of the gastric mass (43239).
 
In response to these concerns, CMS decided not to bundle 43231 with 43202, 43241 with 43239, or 45341 with 45331. CMS did bundle 43232 with 43202, 43242 with 43239, and 45342 with 45331, but those can be overridden with a modifier if the biopsies are performed on two separate lesions. "A provider should not bill for two biopsy techniques on the same lesion," CMS insisted in a letter to the three societies.
 
With these new edits, an endoscopist cannot receive payment separately for performing these radiological interpretative services along with an EUS, says Scottsdale, Ariz., gastroenterologist Joel V. Brill, MD, CPT, and RUC advisor with the AGA. According to CMS, the reimbursement is supposed to cover the radiologic work of the endoscopist who performs the EUS procedure.