Copyright © 2014 AAPCCopyright/Disclaimer text

GI Coding UpdatesRhonda Buckholtz, CPC, CPCI, CPMS, CRC, CDEO, CHPSE, CGSC, COBGC, CENTC, CPEDC

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Fee schedules, relative value units, conversion factors and/or related components are not assigned by theAMA, are not part of CPT, and the AMA is not recommending their use. The AMA is not recommendingtheir use. The AMA does not directly or indirectly practice medicine or dispense medical services. TheAMA assumes no liability for data contained or not contained herein.

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The responsibility for the content of any “National Correct Coding Policy” included in this product is withthe Centers for Medicare and Medicaid Services and no endorsement by the AMA is intended or should beimplied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, nonuse or interpretation of information contained in this product.

• Top GI coding questions• What the new CPT codes are and how to apply them• How the new changes in I10 will apply• Key terms to look in documentation for correct assignment

Agenda

Top GI Coding Questions

• We are trying to get coding information for billing for an injection of epinephrine, in the rectum, applied for hemostasis. A 20ml saline injection for saline pillow, polypectomy performed using a hot snare. And then ablation using a soft coag current at 80 watts. All done in the rectum. Can all three be billed at the same time? We are billing 45388, 45381, 45385.

Top Questions Asked

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• Includes cap-assisted or ligation-assisted (banding) removal of a lesion with injection-assisted snare removal techniques

• Requires the lift technique to create a space beneath the lesion

• Use of a specialized device to isolate the tissue• Include:

• Submucosal injection to lift the lesion• Demarcation of the lesion• Endoscopic snare resection

Endoscopic Mucosal Resection (EMR)

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• Our physician is documenting “A 13 mm polyp was found in the ascending colon. The polyp was sessile. Thepolyp was removed with a saline injection-lift technique using a hot snare. Resection and retrieval were complete.”

• All three need to be documented, if not:• Use individual components

EMR

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• How do I bill for colonoscopy done for surveillance for history of ulcerative colitis? We billed it as a 45380 with a PT modifier and Z87.19. Medicare denied.

Top Asked Questions

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Modifier PT does not apply as it is not a screening colonoscopy. In this case you would resubmit without the PT modifier. Although a screening is done in the absence of signs or symptoms once the patient has a diagnosis of polyps , whether a sessile serrated adenoma, adenma or hyperplastic, follow ups are surveillance, not screening. If the patient has a history of polyps, is now returning for a follow-up exam and is otherwise asymptomatic, tehn the exam is a surveillance colonoscopy. If the previous polyps were benign, tehn we code z86.010 personal history of polyps.

Answer

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We are having a debate in our office due to the ambiguity of the explanation of coding of colonoscopies. In the decision tree it states that if it does not reach the splenic flexure it should be coded as a FS and implies that only if it passes the splenic flexure but does not reach the cecum should the modifier -53 modifier be used. But what if a colonoscopy was panned but didn't reach the splenic flexure for whatever reason and we want to repeat it? Wouldn’t we want to still bill the colonoscopy code with the -53 modifier?

Top Asked Questions

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According to Medicare guidelines, if you perform an incomplete colonoscopy and you plan to repeat it, you would append modifier -53. Medicare rules for colonoscopy differ from the AMA rules, particularly with regard to incomplete colonoscopies. For a Medicare patient undergoing a screening colonoscopy. If the surgeon is able to advance the scope past the splenic flexure, consider the colonoscopy complete and report the appropriate code such as a screening code G0105 colorectal cancer screening; colonoscopy on individual high risk or G0121 colorectal cancer screening colonscopy on individual not meeting criteria for high risk depending on the patients risk factors with no modifier appended. In such a case medicare will pay the standard reimbursement rate for the coded procedure. odifier 52. Some payers follow different modifier rules.

Answer

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Medicare guidance for incomplete, if the physician preps the patient for a screening colonoscopy but cannot advance the scope past the splenic flexure due to obstruction, patient discomfort, etc use modifier 53 per CMS. When a covered colonoscopy is attempted but cannot be completed because of extenuating circumstances Medicare will pay for the interrupted colonoscopy at a rate consistent with that of a flex sig as long as coverage conditions are met for the incomplete procedure. One week after an attempted but unsuccessful screening exam , a high-risk patient returns for a second attempt, this one is successful past the splenic flexure. Initial would be reported G0105-53 and we will get flex sig payment. Medicare rules state we get paid in full for he second exam. For an incomplete colonoscopy with full prep for a colonoscopy use a colonoscopy code with the m

Answer continued

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Colonoscopy done for evaluation of iron deficiency anemia. The scope was passed beyond the splenic flexure, but not to the cecum or colon-small intestine anastomosis, because of inadequate prep. The physician indicates that the patient will be brought back for repeat procedure after re-prep tomorrow.

Top Asked Questions

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Since the exam was incomplete for unforeseen circumstances, and was a diagnostic (not therapeutic) procedure, the patient is returning for complete colonoscopy and modifier 53 should be added to 45378.

Answer

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A 70-year-old male is undergoing high-risk screening due to personal history of transverse colon cancer. The scope was advanced to the ascending colon, but the prep was incomplete and the examination could not be completed. The physician plans to try again after repeat prep.

Top Asked Questions

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Modifier 53 would be added to 45378 for the incomplete first attempt. If the second attempt is complete and no lesions are biopsied or removed, report G0105 for the subsequent procedure.

Answer

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A 65-year-old female, asymptomatic, is undergoing screening colonoscopy. The scope was advanced to the cecum, but prep is incomplete and visibility was not acceptable, thus adequate screening could not be completed. The patient is returning for re-evaluation after repeat prep.

Top Asked Questions

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A 65-year-old female, asymptomatic, is undergoing screening colonoscopy. The scope was advanced to the cecum, but prep is incomplete and visibility was not acceptable, thus adequate screening could not be completed. The patient is returning for re-evaluation after repeat prep. Modifier 53 would be added to 45378 for the incomplete first attempt. If the second attempt is complete and no lesions are biopsied or removed, report G0121 for the subsequent procedure.

Answer

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A 54-year-old is undergoing screening colonoscopy. Obstructing mass found in the transverse colon, which prevented examination of the right colon. Biopsies were taken.

Top Asked Questions

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Modifier 52 and either modifier PT (if a Medicare beneficiary) or 33 (if a commercial, Medicaid, Tricare patient) would be added to 45380. This indicates the procedure was intended to be screening. However, once a biopsy was performed, it became therapeutic. Since it was also incomplete, modifier 52 is reported.

Answer

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2017 CPT Updates

GMMM1 Moderate sedation services provided by the same physician or other qualified health-care professional performing a gastrointestinal endoscopic service (excluding biliary procedures) that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intra-service time, patient age 5 years or older. [0.10 Proposed physician work RVUs]

Moderate Sedation Services Provided by the Same Physician for GI Endoscopy

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99151 –Moderate sedation services provided by the same physician or other

qualified health-care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intra-service time, patient younger than 5 years of age. [0.50 Proposed physician work RVUs]

Moderate Sedation Services Provided by the Same Physician

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99152 – initial 15 minutes of intraservice time, patient age 5 years or olderModerate sedation services provided by the same physician or other qualified health-care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intra-service time, patient age 5 years or older [0.25 Proposed physician work RVUs]

Moderate Sedation Services Provided by the Same Physician

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+99153– Each addition 15 minutes intraservice timeModerate sedation services provided by the same physician or other

qualified health-care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; each additional 15 minutes of intra-service time (List separately in addition to code for primary service). [0.00 Proposed physician work RVUs]

Moderate Sedation Services Provided by the Same Physician

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2017 ICD-10-CM Coding Updates

Digestive

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Periodontitis

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K05.211 Add Aggressive periodontitis, localized, slight

K05.212 Add Aggressive periodontitis, localized, moderate

K05.213 Add Aggressive periodontitis, localized, severe

K05.219 Add Aggressive periodontitis, localized, unspecified severity

K05.221 Add Aggressive periodontitis, generalized, slight

K05.222 Add Aggressive periodontitis, generalized, moderate

K05.223 Add Aggressive periodontitis, generalized, severe

K05.229 Add Aggressive periodontitis, generalized, unspecified severity

K05.311 Add Chronic periodontitis, localized, slight

K05.312 Add Chronic periodontitis, localized, moderate

K05.313 Add Chronic periodontitis, localized, severe

K05.319 Add Chronic periodontitis, localized, unspecified severity

K05.321 Add Chronic periodontitis, generalized, slight

K05.322 Add Chronic periodontitis, generalized, moderate

K05.323 Add Chronic periodontitis, generalized, severe

Necrotizing enterocolitis NEC

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Symptoms include: Abdominal bloating Blood in the stool Diarrhea Feeding problems Lack of energy Unstable body temperature Unstable breathing, heart rate, or blood pressure Vomiting

Staging of NEC uses the Bell Stage classification: Stage 1 Suspected NEC Mildest of symptomsStage 2 Proven NEC cases Signs more indicative of NEC (other gastrointestinal

disorders have been ruled out) Abdominal distention is marked Persistent occult or frank blood in stool may be

presentStage 3 Advanced NEC cases showing stage 1 and 2 Shows a deterioration of vital signs Evidence of septic shock, marked gastrointestinal

bleeding

Documentation concepts include: Type Stage

Necrotizing enterocolitis NEC

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K55.30 Add Necrotizing enterocolitis, unspecified

K55.31 Add Stage 1 necrotizing enterocolitis

K55.32 Add Stage 2 necrotizing enterocolitis

K55.33 Add Stage 3 necrotizing enterocolitis

Necrotizing enterocolitis NEC

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Other additions

K58.1 Add Irritable bowel syndrome with constipationK58.2 Add Mixed irritable bowel syndromeK58.8 Add Other irritable bowel syndromeK59.03 Add Drug induced constipationK59.04 Add Chronic idiopathic constipationK59.31 Add Toxic megacolonK59.39 Add Other megacolonK85.00 Add Idiopathic acute pancreatitis without necrosis or infectionK85.01 Add Idiopathic acute pancreatitis with uninfected necrosisK85.02 Add Idiopathic acute pancreatitis with infected necrosisK85.10 Add Biliary acute pancreatitis without necrosis or infectionK85.11 Add Biliary acute pancreatitis with uninfected necrosis

Necrotizing enterocolitis NEC

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Deletions include codes that were expanded with additions:

K04.0 Delete Pulpitis

K05.21 Delete Aggressive periodontitis, localized

K05.22 Delete Aggressive periodontitis, generalized

K05.31 Delete Chronic periodontitis, localized

K05.32 Delete Chronic periodontitis, generalizedK08.8 Delete Other specified disorders of teeth and supporting structuresK52.2 Delete Allergic and dietetic gastroenteritis and colitisK55.0 Delete Acute vascular disorders of intestineK59.3 Delete Megacolon, not elsewhere classifiedK85.0 Delete Idiopathic acute pancreatitisK85.1 Delete Biliary acute pancreatitisK85.2 Delete Alcohol induced acute pancreatitisK85.3 Delete Drug induced acute pancreatitisK85.8 Delete Other acute pancreatitisK85.9 Delete Acute pancreatitis, unspecifiedK86.8 Delete Other specified diseases of pancreas

Necrotizing enterocolitis NEC

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Revised codes include:

K91.61 Revise fromIntraoperative hemorrhage and hematoma of a digestive system organ or structure complicating a digestive system procedure

K91.840 Revise fromPostprocedural hemorrhage and hematoma of a digestive system organ or structure following a digestive system procedure

K91.841 Revise fromPostprocedural hemorrhage and hematoma of a digestive system organ or structure following other procedure

K91.61 Revise toIntraoperative hemorrhage and hematoma of a digestive system organ or structure complicating a digestive system procedure

K91.840 Revise toPostprocedural hemorrhage of a digestive system organ or structure following a digestive system procedure

K91.841 Revise toPostprocedural hemorrhage of a digestive system organ or structure following other procedure

CEU Code

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ATL221