Gastroenterology Medical Coding – Upper GI Procedures

Gastroenterology is a medical specialty that deals with the digestive system and its disorders. Gastroenterologists use a number of diagnostic procedures to accurately identify the patient’s medical condition and prescribe treatment. Coding for gastroenterology involves accurate coding of the various procedures and services offered by the physician. Reimbursement is offered for procedures provided in in-office, in-facility, hospital outpatient and ASC facility settings. Payment policies vary with individual payers and therefore these should be verified before providing treatment to identify limitations if any, on diagnosis, site of service or coding requirements.

Common Gastroenterology Procedures

• ERCP (endoscopic retrograde cholangiopancreatography) – this procedure combines the use of X-rays and endoscope. It is used to identify disorders such as gallstones, tumors, cysts, blockages and narrowing in the ducts.

• Sphincterotomy – to treat abnormalities diagnosed during an ERCP

• EUS (endoscopic ultrasound) – ultrasound of the pancreas, transduodenal or transgastric

• Sigmoidoscopy – enables the physician to view the lower end of the colon.

• Gastroscopy – this helps to examine the lining of the oesophagus, stomach and duodenum using an endoscope.

• Colonoscopy – is utilized by physicians to have a direct view of the whole of the large bowel or colon.

Upper Gastrointestinal Procedures and Codes

Upper gastrointestinal procedures include endoscopic and esophagoscopic procedures. These help the physician to view the interior of the upper GI tract including the esophagus, stomach and duodenum. When billing for Upper GI procedures, you have to verify payer conditions for covering the procedure. The services are usually covered when medical conditions such as esophageal disease, anemia, gastric ulcer, Celiac disease, persistent upper abdominal symptoms, and involuntary weight loss have been diagnosed.

• 43200 Diagnostic esophagoscopy

• 43202 Esophagoscopy with biopsy

• 43215 Esophagoscopy with foreign body removal

• 43216 Esophagoscopy with electrocautery removal of tumor or polyp

• 43217 Esophagoscopy with snare removal of tumor or polyp

• 43220 Esophagoscopy with dilation

• 43227 Esophagoscopy with control of bleeding

• 43232 Esophagoscopy, rigid or flexible; with transendoscopic ultrasoundguided intramural or transmural fine needle aspiration/biopsy(s)

• 43234 EGD – simple primary examination

• 43235(dagger) EGD – diagnostic

• 43238 Upper gastrointestinal endoscopy with transendoscopic ultrasoundguided intramural or transmural fine needle aspiration/biopsy(s) esophagus (includes endoscopic ultrasound examination limited to the esophagus)

• 43239(dagger) EGD with biopsy

• 43241 EGD with transendoscopic catheter or tube placement

• 43242 Upper gastrointestinal endoscopy with transendoscopic ultrasoundguided intramural or transmural fine needle aspiration/biopsy(s)(includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum and/or jejunum as appropriate)

• 43246 EGD with PEG tube placement

• 43247 EGD with foreign body removal

• 43250 EGD with electrocautery removal of tumor or polyp

• 43251 EGD with snare removal of tumor or polyp

• 43255 EGD with control of bleeding

Certain codes 43200, 43202, 43234, 43235 and 43239 require prior authorization with some payers, and this has to be verified beforehand.

Some Important Considerations

A comprehensive endoscopic evaluation of the upper GI tract has to be reported with the code 43235. This usually involves a detailed view of the esophagus, stomach and duodenum and a thorough examination of the duodenal bulb. Physicians should use code 43239 to report EGD (Esophagogastroduodenoscopy) with biopsy. An EGD that is provided just as a primary examination and does not include “comprehensive” components can be reported with the code 43234. Lesser services such as esophagoscopy and esophagoscopy with biopsy should be reported only using their specific codes, 43200 and 43202 respectively. Physicians should avoid the practice of adding modifier -52 to 43239 to signify these reduced services, because this usually results in pointless delays or even denials of payment. When reporting biopsies and procedures for removing foreign bodies, physicians should take care to choose the code that clearly specifies these.

In cases where more than one procedure is carried out during a single visit, physicians should ensure whether these come under the multiple endoscopy payment rules. Here, Medicare as well as most private payers will reimburse the full value of the highest-valued procedure, along with difference between the value of the remaining procedure and the base endoscopic procedure. Modifier -51 has to be used along with the lesser-valued procedure.



Source by Laura N Jones

Coding for Lower Gastrointestinal Endoscopic Procedures

Lower gastrointestinal endoscopy claims have to show medical necessity, if they are to be reimbursed without fail. This means that the appropriate ICD-9 codes will have to be reported. Usually, Medicare carrier websites publish these codes for GI procedures. Therefore when coding for lower GI procedures, payer specific coding becomes very important.

Lower Gastrointestinal Endoscopic Procedure Codes

ProcedureCPT Code

Diagnostic sigmoidoscopy – 45330

Sigmoidoscopy with biopsy – 45331

Sigmoidoscopy with foreign body removal – 45332

Sigmoidoscopy with electrocautery removal of tumor – 45333

or polyp

Sigmoidoscopy with control of bleeding – 45334

Sigmoidoscopy with snare removal of rumor or polyp – 45338

Diagnostic colonoscopy – 45378

Colonoscopy with removal of foreign body – 45379

Colonoscopy with biopsy – 45380

Colonoscopy with control of bleeding – 45382

Colonoscopy with electrocautery removal of tumor – 45384

or polyp

Colonoscopy with snare removal of tumor or polyp – 45385

Factors to Take into Account When Reporting Lower GI Procedures

Lower GI procedures have to be reported taking into account the scope insertion site and the services the physicians provided during the endoscopy. The length of scope insertion, the approach method, the doctor’s services, and the diagnosis are important factors to note when coding for lower GI procedures. When these are clear in the claims, there is a better chance for accurate reimbursement.

Since there are four distinct code sets for lower endoscopies, it is important to record clearly the extent of scope insertion.

· Choose from the anoscopy code set 46600 to 46615 – Anus (for up to 5 cm insertion)

· Proctosigmoidoscopy codes 45300 to 45321 – Anal canal, rectum and the sigmoid colon (6cm – 25 cm)

· Choose a code from the sigmoidoscopy set 45330 to 45339 – Entire rectum, sigmoid colon, and/or performs an exam of a portion of the descending colon up to the splenic flexure (26 cm to 60 cm)

· Choose from the colonoscopy code set 45378 – 45385 – Entire colon, from the rectum to the cecum (more than 60 cm), and/or the last portion of the small intestine

Once the endoscopic procedure has been correctly identified, the next step is to verify whether the service provided is therapeutic or diagnostic. For diagnostic services, the first code in the appropriate lower GI endoscopy family has to be reported. Therapeutic services have to be reported using the correct therapeutic lower GI endoscopy codes you find below the diagnostic code in each endoscopy family. Care has to be taken to arrive at the proper code by checking the operative notes the physician has provided.

Experienced Medical Billing and Coding Firm Can Assist in Accurate Coding

Coding for gastrointestinal procedures is rather complex and requires in-depth knowledge regarding the diagnostic and procedure codes. Only then can each procedure be coded accurately and reimbursement ensured. Another crucial factor is payer specific coding. You have to know the services that are eligible for reimbursement with individual payers. Established medical billing firms have expert coding and billing staff, state-of-the-art software and excellent quality assurance to make sure that your claims are flawless and submitted on time.



Source by Laura N Jones

Correct Coding and Billing of Orthopaedic Procedures to Get Proper Reimbursement

Like all medical practitioners, orthopedic surgeons are also concerned about getting paid properly on the basis of the work that they do in hospitals and at their practices. Being, as it is, primarily related to medical issues pertaining to bones and the skeletal structure, orthopedics often involve multiple diagnostic tests and procedures, generating a lot of documentation and thus, a lot of coding. These tests and procedures also have to follow the stated orthopedics guidelines, which change and add to the complexity of the task facing every orthopedic surgeon.

It is, therefore, important to get the coding correct at the outset for the services rendered. In the instance that incorrect coding is found for the service provided, there is a possibility that your orthopedics coding reimbursement payment may be reduced, delayed or cancelled altogether. This would mean that the costs of providing that procedure will not be reimbursed, and that your hospital, practice or clinic would lose money for services that it has already rendered. The responsibility for this falls squarely on the primary surgeon.

The reason behind it is that you are the one providing the services, be it in a hospital, office or in the operating room; therefore, you are the sole responsible person, which also makes you liable for the errors. Therefore, it is essential for you, as a responsible medical professional, to learn and be aware of the ICD 10 codes. It is not advisable to use Electronic Health Record (EHR) systems for coding. It is very important that physicians and other staff use the necessary documentation that will help ease in the transition to ICD-10-CM, and make it as seamless as conceivably possible. If you do not know the new code descriptors or codes, the documentation will not match with nomenclature of ICD-10-CM and will not provide the appropriate and specific code – this is where a large number of claims fail to pass muster and orthopaedics coding reimbursement becomes problematic.

You cannot rely 100% on your staff for correcting your code, simply because your staff will never have the same stake that you have in ensuring proper coding; regardless of their training or expertise. Being aware of the coding requirements and orthopedics guidelines of a procedure is always going to save you time, money and effort in the long run. This will help you increase your revenues and profit and be a better value generator in your professional career.

The Centers for Medicare & Medicaid Services (CMS) has clarified the documentation requirements and policy requirements for the use of CPT® modifier -25 used with E/M services. The implementation of ICD-10-CM will not impact how you report CPT codes, including proper modifier placement. Thus, being aware of the current state of coding and remaining aware of orthopaedics guidelines has become an incredibly important part of being an orthopaedic surgeon.



Source by Steve Gray Stevenson