When the American Medical Association (AMA) released the 2014 Current Procedural Terminology (CPT) code set, 25 percent of all changes constituted those made to the gastroenterology codes. The changes include 26 new codes, 41 revised codes and 17 deleted codes while new codes have been introduced to capture the advances in endoscopic technology, devices and techniques. A transition grid was also developed by the AMA to help providers in a smooth transition to the revised GI codes.
- There is a significant change in endoscopy codes and their definitions. The guidelines also clarify that the control of bleeding resulting from an endoscopic procedure cannot be reported separately during the same operative session.
- New codes for endoscopic mucosal resections or EMR (43211 (esophagoscopy), 43254 (EGD)).
- New guidelines for stent placement such as pre/post dilation and guide wire passage are included in stent codes, if performed. There are new codes for stent placement (43212 (Esophagoscopy), 43266 (EGD), 43274 (ERCP)). Codes 43219, 43256, 43268 have been deleted.
- A new code for dilations (43277: ERCP with balloon dilation of biliary/pancreatic duct or of ampulla).
- Fluoroscopy codes have revisions in coding language and new guidelines have been introduced for billing fluoroscopy separately.
A major change is also there in appending modifiers when only the esophagus and stomach are examined, not the duodenum. If a repeat examination is not planned, it is required to append the modifier -52. In case a repeat examination is planned, the physician would append the modifier -53 and the Ambulatory Surgery Centers (ASC) would append the modifier -74.
How Does This Affect Gastroenterology Practices
In the opinion of healthcare experts, these changes mean a lot for gastroenterologists as well as GI-driven ambulatory surgery centers. Here are the main aspects on which they can expect changes as per the experts.
- Specificity – With the new code set, there is increased need for specificity and gastroenterologists are required to provide more information for coders to choose the correct codes. For example, earlier general codes were used for esophagoscopy. Now, it is required to specify whether the scope was introduced transorally or transnasally and whether the scope was rigid or flexible as there are separate codes available for all these cases.
- Codes 43191-43196 for esophagoscopy with rigid scope using a transoral approach
- Codes 43197-43198 for flexible esophagoscopy with a transnasal approach
- Codes 43200-43232 for flexible esophagoscopy using a transoral approach
Gastroenterologists have to adopt newer ways of looking at diagnoses and treatment as well as take a closer look at clinical documentation.
- Reimbursement – Experts suggest most GI-driven ASCs and gastroenterologists rely on traditional endoscopy and colonoscopy as these procedures are highly profitable and continuing this trend after new changes will cause them reimbursement pressure as these are now mainstream procedures. However, the new codes provide more reimbursement opportunities as well. For example, code 4327, used for the ablation in Barrett’s esophagus cases is a good addition for which Medicare pays $550. Two significant codes which were reimbursed only in hospitals have been added to the ASC Medicare list also.
- 60240: Thyroidectomy with an average Medicare payment of $2,160
- 60500: Parathyroidectomy with an average Medicare payment of $1,938
These procedures can be performed by the ASCs on healthy Medicare beneficiaries. Overall, diversification of GI procedures among practices can drive towards broader and more reliable reimbursement base.
- Technology – If traditional GI procedures are likely to see a long term decline in reimbursement, gastroenterologists can fill that gap by keeping up with new technologies according to the experts. Though not all new procedures receive steady reimbursement, keeping abreast of technological advancements is undoubtedly a beneficial strategy for gastroenterologists. Endoscopic Retrograde Cholangiopancreatography (ERCP) is an advanced technique and now there is a new code available for ERCP with balloon dilation of biliary/pancreatic duct or of ampulla. If the physicians have not explored this technology, they will lose the opportunity to use this code and receive reimbursement.
- Claim Denials – Any significant coding changes bring concerns of errors and claim denials. In this case also, errors may happen due to underpayment or lack of knowledge about a new code. However, the following measures can help avoid such kind of denials to a great extent.
- Obtaining proper authorization
- Understanding patient benefits and verifying eligibility
- Taking efforts for accurate documentation
- Submitting clean claims within the deadline
Expert Tips for Successful Implementation of New Changes
- Identify separately reportable services during endoscopy procedures itself for receiving good reimbursement.
- Set up new reporting guidelines for endoscopic celiac nerve injections to avoid claim denials.
- Keep tabs on specific instances when a sphincterotomy can’t be billed separately so as to avoid audit.
- Use correct codes for controlling bleeding so that a GI doctor can receive accurate payment for the services rendered.
- Capture all reimbursement in an ethical manner when multiple stents are placed.
- Ensure that you follow all necessary GI code revisions to avoid significant claim denials.