Vol. 12 •Issue 19 • Page 10
Gastrointestinal CPT Coding Is a Challenge
Put your gastrointestinal coding thinking caps on! In this column, we will be focusing on the sometimes-difficult area of GI CPT code assignments. We will address the CPT coding and modifier use. First, let’s discuss a few tips for the gastrointestinal chapter. Be aware that we will only touch on several of the areas in this chapter. Due to limits on space, only the codes are presented. Please refer to your CPT code book for descriptions.
1. The gastrointestinal system CPT codes cover 40490-49999. The GI subsection of CPT covers the following anatomical subheadings: lips, mouth, tongue and floor of mouth, dento-alveolar structures, palate and uvula, salivary gland and ducts, pharynx-adenoids-tonsils, esophagus, stomach, intestines, Meckel’s diverticulum and the mesentery, appendix, anus, liver, biliary tract, pancreas, abdomen-peritoneum-omentum. This is quite a list! I recommend that you become familiar with the procedures under each subheading to get a feel for the location of codes. The CPT index is at times difficult to use to locate procedures. When coding, it is important that you always look at the subsection, heading and subheading of the procedure you are coding. The CPT book index may not always have the procedure listed in a logical place.
2. Follow any overarching CPT guidelines located in the “Introduction” chapter and the “surgery guidelines” located just before the “Surgery” section of the CPT book. They instruct you on common conventions such as “CPT Surgical Package Definition,” “Add on codes,” and “separate procedure.” If you come across (separate procedure) in the CPT code description, pay particular attention to this. The separate procedure is not to be reported in addition to the code for the total procedure or service of which it is considered an integral component. If the separate procedure is the only service provided, or is provided at the time of an unrelated procedure, however, the code can be assigned. For example, look at codes 43235, EGD, (separate procedure) and 43243, EGD with injection sclerosis of esophageal or stomach varices. 43235 would not be reported in conjunction with 43243. If however, the EGD is performed with an unrelated procedure such as a skin lesion removal, then both the EGD 43235 and skin lesion removal code would be reported. Look at code 44005 for enterolysis as well.
3. Read and be guided by information contained in the CPT Assistant issues. You should review all GI related articles. For example, look at CPT Assistant, April 2000, p. 10 and January 2000, p. 11. The question is in regard to reporting enterolysis of adhesions in conjunction with a hernia repair (49495-49659 with 44005). CPT Assistant responds that 44005 is designated as a separate procedure and is considered an integral part of the hernia repair codes and should not be reported separately. However, if the enterolysis is extensive per the physician, and added significantly to the overall procedure, modifier -22 can be added to the hernia repair code on the physician’s claim for the professional fee. For hospital outpatient surgery coding, Medicare triggers OCE edit 045 and 020 and consider the code integral to, with payment for the hernia repair code only.
4. A surgical endoscopy code always includes a diagnostic endoscopy so there is no need to report both. The separate procedure rule usually takes care of this.
5. For a total colonoscopy, this includes examination from the anus to the cecum, and may include the terminal ileum. Do not report a separate code for the terminal ileum viewing if done with the colonoscopy. If the entire colon is not viewed, code to the highest level viewed (i.e., sigmoidoscopy, proctosigmoidoscopy, etc). Be sure to look at the approach, as there are separate codes for a colonoscopy through the natural orifice and through a colostomy. Review the instructional notes in the endoscopy subheading of the GI section of CPT. Modifier Ð52 (45378Ð52) is used if the physician is not able to complete any portion of the colonoscopy after inserting the scope. This may happen when there is poor prep and nothing can be viewed.
6. For Medicare hospital patients, there are “screening colonoscopy” G -codes for patients undergoing screening for colorectal cancer. Code G0105 is for high risk individuals, who have one of the following:
•close relative such as sibling, parent or child with colorectal cancer or adenomatous polyposis;
•a family history of familial adenomatous polyposis;
•a family history of hereditary nonpolyposis colorectal cancer
•a personal history of adenomatous polyp;
•a personal history of colorectal cancer;
•inflammatory bowel disease, including Crohn’s disease and ulcerative colitis.
Code G0121 is used for a screening colonoscopy for a beneficiary NOT meeting the high-risk criteria. If a lesion is found and biopsied OR removed, you then code the surgical colonoscopy code instead of the G code. You will most likely have diagnosis code V76.51 for the screening colonoscopy. Screenings are performed on patients who do not have signs or symptoms. If the patients have signs and symptoms and are having the colonoscopy to find the cause, then this is a diagnostic colonoscopy and regular CPT colonoscopy codes should be used. This may or may not be on the exams, however specific Medicare questions have been known to appear on the exams in the past.
7. If a biopsy of a colon lesion is obtained and the remaining portion of the same lesion is then excised, code only for the excision. If a biopsy is taken from one lesion, and an excision of a DIFFERENT lesion is performed, code both procedures. It is appropriate to assign modifier Ð59 to the second code in this instance for Medicare patients. If more than one polyp is removed using the same technique, assign only one code.
8. If more than one procedure is performed through the endoscopy, code all performed. For example, if an EGD is performed with band ligation of esophageal varices and there is also snare removal of an esophagus polyp, report codes 43244 and 43251.
9. If one polyp, tumor or lesion is removed with both snare and hot biopsy techniques, report only the CPT code for the snare technique. If a colon polyp is removed by cold biopsy forceps, the code depends on whether the polyp is biopsied or removed. If biopsied, code 45380. If removed, use 45385 as the jaws at the tip of the forceps (as opposed to a loop) surround the polyp at the stalk just like the snare and severs its attachment to the colon mucosa.
10. For hernia repairs, be careful of the type of hernia, such as inguinal, incisional, umbilical, epigastric, etc. CPT codes are assigned by type. Also beware of whether the hernia is a new or recurrent hernia, and if it is reducible or if it is incarcerated or obstructed. These all affect the code assignment. Some codes take into account the age of the patient. For incisional or ventral hernia repairs using Mesh, an additional code is reported, 49568. All other hernia repair codes include the mesh and it is not separately assigned.
11. Laparoscopic hernia repairs, which are increasingly being performed, are coded to 49650-49659.
12. Modifiers are used on hernia repairs to denote site as -LT, -RT or Ð50 (bilateral) on hospital Medicare patients (CCS exam). They are not used overwhelmingly in physician professional fee coding (CCS-P). There was some controversy on this because Medicare initially stated that the ÐRT, -LT and -50 modifiers applied only to “paired organ systems,” however, it is common practice to assign these modifiers for hernia repairs. Medicare states “-50 applies to any bilateral procedure performed on both sides at the same session.” Inguinal hernias occur on one or both sides. Individual payers may or may not require modifiers.
13. Inguinal hernias are direct, indirect or both. A direct inguinal hernia protrudes through or into the abdominal wall between the deep epigastric artery and the edge of the rectus muscle. An indirect inguinal hernia involves the internal inguinal ring and protrudes into the inguinal canal. This affects ICD-9-CM coding but not CPT coding.
14. Unfortunately, there is no code for removal of teeth in CPT. You must use the unlisted code, 41899 (unlisted dentoalveolar procedure).
15. For esophageal dilation, first identify the method of dilation such as balloon, dilator, bougie or guidewire. These codes also identify medical conditions requiring dilation in some instances (achalasia 43458). Code 43450 is dilation without visualization. Dilation can also be performed either endoscopically or non-endoscopically.
Now, answer the following questions. Research the CPT Assistant if applicable. Due to limits on space, only the codes are presented. Please refer to your CPT code book for descriptions.
A) A patient undergoes a colonoscopy. Following placement of the Olympus CF 100 video colonoscope, the terminal ileum was viewed and the distal 10 cm appeared inflamed. A biopsy was taken from this area. The scope was withdrawn back into the cecum where multiple biopsies were taken. The scope was further withdrawn and two separate polypoid lesions were resected with the polypectomy snare. There was some adjacent villous adenomatous mucosa that was biopsied. At the area of the hepatic flexure, another polyp was removed with the polypectomy snare. The scope was removed.
1. 45385, 45385, 45380, 45380
2. 45385, 45385-59, 45380-59, 45380-59 (or Ð51 for physician office)
3. 45385, 45380-59 (or -51 for physician office)
4. 45385, 45380, 45385-59 (or -51 for physician office)
B) The patient undergoes an EGD with biopsies and dilation of an esophageal stricture. The EGD was placed into the esophagus where stricture and esophagitis was noted. This area was biopsied. The scope was taken to the second portion of the duodenum and slowly withdrawn to the stomach where further biopsies were taken. The scope was withdrawn to the esophagus where a 20 mm balloon was inserted and the esophageal stricture was dilated. The scope and dilator was then withdrawn.
1. 43249, 43239 (with -51 for physician office)
3. 43249, 43239, 43239-59 (with -51 for physician office)
4. 43456, 43239
C) A 4-year-old patient is to have repair of left initial inguinal hernia with mesh and hydrocelectomy.
3. 49505-LT, 55500-LT-59 (or -51 for physician office)
4. 49500-LT, 55500-LT-59 (or -51 for physician office)
D) A 50-year-old patient has two hernias. A left inguinal hernia is repaired laparoscopically and an umbilical hernia is repaired openly.
1. 49650-LT, 49585 (and -51 for physician office)
2. 49507-LT, 49585 (and -51 for physician office)
3. 49505-LT, 49585 (and -51 for physician office)
E) A patient undergoes ERCP with removal of stent and sphincterotomy.
2. 43269, 43262 (add -51 for physician office)
3. 43269, 43260-59, 43262-59 (add-51 to two procedures for physician office)
4. 43260, 43262 (add -51 for physician office)
Patricia Maccariella-Hafey is director of education for Health Information Associates Inc., a company specializing in providing coding compliance review services, education and contract coding for hospitals. The corporate office is headquartered in Pawley’s Island, SC.
Coding Clinic is published quarterly by the American Hospital Association
“CPT only© 2001 American Medical Association. All Rights Reserved.”
A) 3; -45385, 45380-59 (or Ð51 for physician office) (the code 45380 description states “with biopsy, single or multiple” so only one code is needed for multiple biopsies. Code 45385 descriptor states “with removal of polyp(s) denoting more than one polyp can be removed with only one code being reported) See CPT Assistant February 1999 page 11.
B) 1; 43249, 43239 (with -51 for physician office) (again, 43239 description has “biopsy, single or multiple” hence only once code). The dilation was also done endoscopically. Current edits are not requiring a modifier of Ð59 but this may be required by your FI.
C) 2; 49500-LT (code 49500 states “with or without hydrocelectomy” so is included. Code 55500 is a separate procedure. See CPT Assistant Winter 1994 page 13-14. The patient is also 4 years old, which affects the code.
D) 1; 49650-LT, 49585 (and Ð51 for physician office)
E) 2; 43269, 43262 (add Ð51 for physician office)