Coding and Reimbursement - DRAFT - American College of Gastroenterology

ACG Practice Management Toolbox
Members Only – ACG’s Billing & Coding Forum

We heard you! ACG members and GI practices continue to face mounting financial and reimbursement pressures. Complex coding and documentation requirements only add to these burdens. The ACG Practice Management Committee is pleased to announce the new member benefit: professional coding and documentation assistance for ACG members, tailored to your individual practice’s questions and needs.

Arlene Morrow, CPC, CMM, CMSCS is now available to answer your questions!

Have a question? Email coding@gi.org – ACG members will receive an answer and guidance within a few business days.

Helpful Coding Q&A’s for ACG Members

Colonoscopy

Question: We recently have been getting guidance from our billing compliance staff that we have been incorrectly using the -59 modifier for colonoscopy coding. For example, when we have a polyp in the ascending removed by snare and another polyp in the transverse colon removed by biopsy we are told to append modifier -XS to the second code (45380) instead of -59 (which was what we had been doing for years). Can you clarify this for us?

Question: During endoscopic procedures, we have been obtaining biopsies and placing manometry catheters for subsequent gastric (CPT:91020), duodenal (CPT:91022), and colonic (CPT: 91117) manometry studies. Questions: For the procedures related to the placement of the motility catheters, would we be able to bill:
1. EGD with biopsy (CPT:43239) and EGD with tube placement (CPT: 43241) for the EGD with biopsies and antroduodenal motility catheter placement
2. Colonoscopy with biopsy (CPT: 45380) and Colonoscopy with stent placement (CPT: 45389) for the colonoscopy with biopsies and colonic motility catheter placement. The technique used for the colonic motility catheter placement is the same as that used for stent placement.
We use fluoroscopy during the placement of the catheters to ensure we are placing them in the correct location without looping. My understanding is that fluoroscopy is not separately billed for.

Question: With new legislation, I wanted to clarify… is it correct that patients will no longer be billed for a diagnostic colonoscopy if it follows a positive stool test?

Question: Another issue has developed in our billing office; coverage for screening colonoscopy in patients 45-50 years old. Several guidelines support screening average risk individuals starting at age 45. We are getting push back from some providers (the most frequent offender is BC/BS). I enclosed a recent communication we received (see below); putting the responsibility on the patient to contact the member service department. Are there any additional codes/modifiers to be used in this situation to avoid future appeals and possible delays in this life saving procedure?

Question: What would be an appropriate consultation level code for evaluation of screening colonoscopy in patients with or without significant medical problems?

Question: Which modifier do you use if an EGD and colonoscopy are done on the same day? We are currently using 51. Second question – when doing EGD CPT 43235 and Maloney dilation CPT 43450 is done, do you bill using modifier 51, 59, just bill each CPT code or just Maloney dilation? These modifiers are the most confusing.

Question: Sometimes during a colonoscopy I may end up removing a polyp with cold forceps and another polyp with cold snare. Can I bill for both and how many RVU’s do I earn?

Question: I have a question regarding colonoscopy reimbursement. I know that removing a polyp in different segments of the colon you can add a modifier to bill higher, what about if you use the same instrument but in different part of the colon? Can that be billed differently? Another question is can cold snare and hot snares be billed different? Most of the time hot snare polyps are more complicated so I’m wondering if they can be billed higher and if so what modifier to use? Thanks.

Question: In the past, colonoscopies performed after a positive Cologuard test were considered diagnostic rather than screening and had to be billed as such. I heard that there were recent changes that allow for colonoscopies performed after a positive Cologuard test to be billed as screening. Is this true? Can you cite the source of the ruling if it is true? Thank you.

Question: I wanted to seek your expertise about billing in regards to a direct access colonoscopy (colonoscopy performed without office visit prior). I spend about 5-10 minutes reviewing patient’s chart prior to approving direct access colonoscopy. In addition, I spend approximately another 5 minutes with patient prior to the procedure confirming history, discussing procedure, and answering any questions. I understand you cannot bill Medicare for consult/new patient visit in addition to procedure for colorectal cancer screening (Z12.11). Is it appropriate/possible to bill for same day consult/new patient visit for commercial payers (United, Cigna, BCBS, Aetna) with modifier 25? A brief pre-procedure note is written with HPI, physical exam and plan. Any insight on whether Consult level 2 or level 3 is appropriate? Thank you for your help.

Question: When you do a biopsy CPT code 45380 and originally patient’s diagnosis is ICD-10 Z80.0, can you bill it like this and get reimb? Medicare patient.

Question: If I remove two polyps, one with a cold biopsy and the other one with cold snare polypectomy, can I use both 45380 and 45385?

Question: If I use clip or epinephrine injection for control of post-polypectomy bleeding, what code should I use with 45380 or 45385? If I use endoloop for prevention of postpolypectomy bleeding, what code should I use with 45385?

Question: Two questions regarding coding:
1. What will be the CPT code for Medicare or non-Medicare private patient if you do colonoscopy – high risk screening and found polyp and did snared polypectomy? Should I also use modifier? And which one?
2. If you’re doing a surveillance colonoscopy for a patient with inflammatory bowel disease for colon cancer, what will be the CPT code for Medicare / non-Medicare private patient and what modifier should I use? Thank you.

Question: Is pre-screening colon office visit covered by insurance? I am using Z12.11
CPT 99203, we are seeing occasional denials.
Is there a better way to code for office visits prior to screening?
Also, is a positive cologuard a covered reason for screening colonoscopy now? I know the legislation has changed recently, not sure from when I can use it as an indication and still have the procedure covered?

Question: I have been getting irate phone calls from patients and their referring primary physicians over the coverage of colonoscopy as diagnostic instead of screening after a positive Cologuard. I recall there was some kind of edict from the federal government to the effect that this should be covered as screening. Do you have any useful information on this? Perhaps a drafted letter from the ACG?
https://www.fightcancer.org/releases/new-guidance-administration-helps-ensure-coverage-follow-colonoscopies-will-save-lives

EGD

Other GI Procedures

Question: If a patient is in observation can we use ER place of service 23 or should we use 22 for outpatient?

Question: I was wondering if when I see cirrhotic patients if I can bill the PCM code?

Question: Previously we had been using CPT code 91010 (esophageal motility study with interpretation and report). Now we are being asked to use CPT code 91299 (unlisted diagnostic gastroenterology procedure) per recommendations from our coding educator. She pointed to guidance from a CMS endorsed program.

During our discussion it was noted that in 2016, code 0240T, which had been assigned for high-resolution esophageal studies with interpretation and report was deleted. However, a replacement code specifically stating it is for high-resolution esophageal manometry is not available. Per the coder’s guidance, because we are performing high-resolution esophageal evaluations, the recommendation is not to use 91010 but rather 91299. Thank you in advance for any insight.

Other GI Services

Question: Am I allowed to bill a 99213 or 99214 office visit for a patient with inflammatory bowel disease who comes to my office for an Entyvio infusion? I am also billing for the Entyvio infusion on the same day with code J3380. I document a full note in EMR for the 99213 or 99214 office. If allowed, does the office visit need to reflect a different GI issue other than inflammatory bowel disease? For example, the patient may be complaining of severe GERD and may need an EGD.

Question: Is there a way to get payment for multiple interventions completed during procedures such as biopsy/snare or biopsy/dilation etc.?

Question: Inquiring minds would like to know how the 82270 and the 82272 are different. As in examples. Help is appreciated.

Question: Can you provide me with facility fee codes which yield payments? Which insurances pay and do I need modifiers to get payment?

Is there a counseling code for discussing diet changes to include fiber and losing weight?

Additionally, if I wanted a check up to ensure that I am coding correctly, is there a way I can do that?

Question: Should you use 99219 or 99220 for GI consult in Observation?Should 99284 ever be used for GI consult in the ED? If not, which consult code should you use?

Question: I have a question about coding and documentation of high resolution ano-rectal manometry. I saw a patient in the office for fecal incontinence and documented the indication and sent her for manometry to a hospital based manometry lab. I had previously set up a protocol for ano-rectal manometry. A nurse obtained the measurements and I then read the recording and provided an interpretive result. The office visit was billed as an office visit. I have the following questions about coding and documentation:

This is the guidance from the manufacturer:
Anorectal Use: CPT© code 91122- Anorectal manometry.
ManoScan™ AR high resolution manometry system performed at the hospital outpatient department
Professional charge 91122-26
Site of service 19 or 22
Date of service Date of report interpretation
Facility charge 91122
Date of service Date of the procedure

1. Is there no procedural charge or is the procedural charge for the nurses activity built into the facility charge or does CMS not consider this a procedure or too minor an intervention to be a procedure?
2. We do balloon distention testing in addition to pressure measurements and generally choose two codes for anal pressure measurement and tone.

Question: We’ve hired a new staff member who did billing for a private practice surgeon who did endoscopic procedures at the hospital and she says they would regularly submit 99202/99213 with a 25 modifier and Z01.818 for the H+P done before all endoscopic procedures (on the day of the procedure). The case they would make is that the H+P is “separately identifiable” from the procedure and the information documented in the H+P is “significant” due to the degree of information obtained. This falls into the grey area of the language that defines the code as I suppose this is technically true, but from what I can gather this may be considered unbundling because the basic H+P is bundled into the procedure code. When I brought it up with my billing company they had a lot of reservations about doing this, so I wanted to run it by the ACG coders. I suppose it comes down to what degree of H+P is included in the bundled code because if we are obtaining more information, then it would be considered significant. I was also curious about this because it is common place amongst many practices to have a pre-procedure clinic visits before screening procedures which is really no different from what is done during the pre-procedure H+P and if that clinic visit gets paid, I feel the work done right before the procedure ought to be paid (though at a lower rate since it uses a 25 modifier).

I was planning on submitting these codes for all of my diagnostic procedures as these procedures often result in management decisions post-procedurally and it is very common for patients/families to discuss symptoms with me post-procedurally which creates what feels like a miniature office visit. In terms of documentation, I have the pre-procedural H+P and the procedure note. I historically document my recommendations/management on the procedure note. Would it be best practice to keep the procedure note basic (i.e., follow up biopsy results) and create a quick separate note outlining my conversation post-procedurally with management recommendations? Another situation where I was thinking this code would be reasonable is when patients have diverticula and I make recommendations on fiber and discuss risk of diverticulitis post-procedurally or when folks want to discuss ways to reduce their risk of polyp formation. Is documenting recommendations in the procedure note okay or is it best to submit these conversations and recommendations in a separate note?

Answer: First let me say that I admire and appreciate the professionalism displayed by your billing company. They understand, as I do, that there are two major reasons to strongly discourage the recommendations from your new biller:

Medical necessity is the overarching criteria to bill for any services and that argument was lacking in these scenarios – the gray area. Strong documentation of medical necessity for a separately reportable E/M assessment is essential to override the surgery package definition – which is definition of 25 modifier. For instance, if there is a cardiac or pulmonary problem identified during pre-op or positive COVID test that may require you to cancel or postpone surgery, that would meet the medical necessity/reasonableness test.
As per the CPT Surgery guidelines (pg 88) In defining the specific services “included” in a given CPT surgical code, the following services are always included in addition to the operation per se:
- subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of the procedure (including history & physical);
- immediate postoperative care, including dictating operative notes, talking with family/other physicians;
- writing orders;
- evaluating the patient in the post anesthesia recovery area; typical postoperative follow-up care

Also per NCCI Chapter VI, E&M service on the same DOS as minor surgical procedure is included in the payment for the procedure.

In conclusion, it would be my professional opinion that billing those H&Ps would not successfully withstand the scrutiny of a post payment payer review and those moneys would be recouped over a “paid claims universe” with crippling financial penalties.

Question: We would like to know if there are other GI’s having a problem with specifically Aetna when billing a hospital follow up with a procedure and attaching the 25 modifier to the follow up CPT. We are all of a sudden getting denials stating incidental. They are also denying our multiple procedure modifiers 59 and 51. Please help.

Follow up — Thanks for that information. We do not use surgery codes. We use diagnostic testing CPTs like 45380 or 43239 or 91065.

Answer: Medicare and other payers are now regularly targeting the improper overutilization of modifier -25.

Per CPT and NCCI, an E&M service on the same DOS as minor surgical procedure is included in the payment RVUs for the procedure.
Strong documentation for a significant separately reportable E/M assessment is needed to override the surgery package definition. A routine visit is bundled into the package.
Examples would include a new or worsening or emergent problem addressed that day that led to the procedure decision.
My recommendation is to be more discerning before assigning the 25 modifier.

Thank you for the follow up question.

Technically, the 25 modifier is an EM modifier used to describe a significantly, separately identifiable visit on same day as another procedure/surgery or other service. All coding software recognizes that our 40000 CPT codes are listed under the surgery section of the CPT book so they consider 45380, 43239 as procedure/surgery and 91065 under the Medicine section. The same principles I mentioned in my previous answer apply. Payers in the last few years have begun denying the 25 routinely because they feel we have improperly used the modifier and likely do not have proof to overturn their denial which in most cases is true.
I apologize that I missed the second part of your question regarding 59 and 51. We would report the 51 modifier to describe multiple procedures in a different family of endoscopy for colonoscopy (i.e., 45385) and EGD (45239-51).
An effective Modifier 59 Coding tip is to use your Box 19 comment /claims narrative field to show this combination of codes should not be bundled. This feature files electronically and dramatically reduces the suspended claims and records requests to adjudicate the 59 claim. CPT 45385 and 45380-59 (or XS) is often a target for payer and automatic denial with reason N19 (bundled and not separately payable). Endoscopy report must clearly show separate location of the lesions treated and the instrument used. A statement of snare polypectomy in the transverse colon and random biopsies obtained in the ascending and descending colon does not clearly state that a different instrument was used and when reviewed by the payer, the previous decision won’t be overturned. Provider should state “random cold forceps biopsies of the ascending and descending colon were obtained.” I hope this helps.

Question: I am an ACG member / GI doc and have a couple of GI coding questions:

1. Can we code D84.821 as a separate diagnosis in addition to one of the IBD codes in our patients with Crohn’s or UC taking immunosuppressant medications (prescribed by the GI doc)? I’m thinking of office visits, where 1 vs 2 stable conditions / diagnoses could make a difference in MDM complexity and impact determination of a level 3 vs level 4 visit. (For our practice, D84.821 also has importance as an additional HCC code.) Do we also use Z79.899 or Z79.52?
2. Do the moderate sedation codes translate into any “work” RVUs or only “facility” RVUs (I am told there is a difference). Our work RVUs are now being tracked by the practice, and it sounds like the sedation RVUs are not attributed to us in that category.

Question: Can we use Principle care management codes for our chronic diseases like UC, Crohn’s, cirrhosis?

Medicare Coding Look-Up

Have a question on a particular Medicare physician fee schedule (PFS) code and reimbursement in your practice area? CMS provides a tool for physicians and practice managers to help answer coding and other reimbursement information in the Medicare PFS.

To access the CMS Physician Fee Schedule Search Tool, visit: www.cms.gov/medicare/physician-fee-schedule/search.

GI Moderate Sedation

ACG Guidance on GI Moderate Sedation and GI Anesthesia Changes — What Do You Need to Know?

GI Moderate Sedation

In 2017, CMS announced changes regarding moderate sedation for certain GI procedures. These changes remain the same for 2018. If you administer moderate sedation while performing certain GI endoscopic procedures, Medicare requires ACG members to report 2 codes on Medicare claims for endoscopic procedures — the code for the endoscopic procedure and a GI-specific moderate sedation code (G0500). If you use an anesthesia professional, you can simply report the procedural code as you have previously done.

Check out ACG’s Moderate Sedation Summary and Educational Tool. ACG has created a summary of these changes and a chart of impacted codes.

GI Anesthesia Changes

Beginning 2018, the following GI anesthesia codes will be deleted: CPT codes 00740 (Anesthesia for upper GI procedures) and 00810 (Anesthesia for lower GI procedures). The CY 2017 base unit for both upper and lower GI services was 5 base units. These codes will be replaced with 5 new codes:

00731 (Anesthesia for upper GI, not otherwise specified) = 5 base units
00732 (Anesthesia for upper GI, ERCP) = 6 base units
00811 (Anesthesia for lower GI, not otherwise specified) = 4 base units
00812 (Anesthesia for screening colonoscopy) = 3 base units
00813 (Anesthesia for upper and lower GI during the same session) = 5 base units

Each base unit is approximately $22.

ACG Practice Management ToolboxMembers Only – ACG’s Billing & Coding Forum

Helpful Coding Q&A’s for ACG Members

Colonoscopy

EGD

Other GI Procedures

Other GI Services

Medicare Coding Look-Up

GI Moderate Sedation

ACG Practice Management Toolbox
Members Only – ACG’s Billing & Coding Forum