Section 3134 of the Affordable Care Act instructs the CMS Secretary to regularly review Medicare fee schedule rates for physician services to identify potentially misvalued codes. Misvalued codes can include procedures with fast growth, substantial change in practice expense, new technologies or services, multiple codes frequently billed together, codes with low relative values, and Harvard-valued codes. In the 2011 Medicare Physician Fee Schedule Final Rule, CMS identified a number of endoscopic procedures for review of physician work and practice expense.
In response to this review and identification of potential improvements, the esophagoscopy (43200-43232), esophagogastroduodenoscopy (EGD) (43235-43259), esophageal dilation (43450-43458) and endoscopic retrograde cholangiopancreatography (ERCP) (43260-43273) code families have been updated to reflect current terminology and practice.
By 2014, the AMA’s CPT Editorial Panel will have completed its review of codes from every GI endoscopy family. Following approval by the CPT Editorial Panel, codes are surveyed by the specialty societies and presented to the AMA/Specialty Society Relative Value Update Committee (RUC). While the RUC makes recommendations to CMS, CMS is the only entity that makes relative value decisions regarding physician work, practice expense and professional liability. Your continued participation in these surveys is critical. The following table outlines the survey schedule and expected implementation of the new codes.
General Concepts for Upper GI Endoscopy Procedures
In recent years, the CPT Editorial Panel has been replacing the terminology “with or without” in codes throughout the CPT book with “including, when performed” in an effort to standardize the language and make the code descriptors more accurate. Current esophagoscopy, EGD and ERCP base codes contain the language “diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure).” New language replaces “with or without” with “including, when performed.” This represents an editorial change and would not change the way the codes are reported.
Placement of Stent
Codes for placement of endoscopic stents may/may not include pre-dilation. The codes now include pre-dilation, post-dilation and guide wire passage, when performed. The code for placement of stent should be reported without a reduced services modifier 52 even if all three components (pre-dilation, post-dilation, guide wire passage) are not performed during the same session. Separate reporting of pre-dilation, post-dilation or guide wire passage is also not appropriate, as these services are now bundled into the code for the placement of the stent.
Control of Bleeding
Previous code descriptors for control of bleeding codes included a list of examples, such as injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler and plasma coagulator. The current descriptor now replaces all examples with the simplified “any method.”
The new ablation codes include pre- and post-dilation and guide wire passage, when performed. Separate reporting of pre- or post-dilation or guide wire passage is no longer appropriate, as these services are bundled into the code for ablation. These ablation procedures are also not reported with a reduced services modifier 52 when all three components (pre-dilation, post-dilation or guide wire passage) are not performed during the same session.
The new set of endoscopy codes also provides more specificity with separate codes for rigid, flexible and trans-nasal esophagoscopy procedures.
A new definition of esophagoscopy describes the typical examination:
Esophagoscopy includes examination from the cricopharyngeus muscle (upper esophageal sphincter) to and including the gastroesophageal junction. It may also include examination of the proximal region of the stomach via retroflexion when performed.
New codes for the esophagoscopy family include endoscopic mucosal resection, retrograde dilation and dilation with balloon greater than 30 mm diameter. Revised codes address appropriate reporting for stent placement, control of bleeding and ablation.
The following definition now applies to the EGD examination service:
To report esophagogastroscopy where the duodenum is deliberately not examined [e.g., judged clinically not pertinent] or because significant situations preclude such exam [e.g., significant gastric retention precludes safe exam of duodenum], append modifier 52 if repeat examination is not planned or modifier 53 if repeat examination is planned.
Guide Wire and Dilation
Previously, insertion of guide wire followed by dilation over guide wire was a separate code and a separately reportable service. For 2014, insertion of the guide wire is followed by passage of the dilator(s) through the esophagus over the guide wire and is included in the dilation service.
Endoscopic Ultrasound (EUS)
Prior to CPT 2014, the EUS codes included examination of the esophagus, stomach, and either the duodenum and/or jejunum, as appropriate. These codes now include examination of surgically altered stomach in which the jejunum is examined distal to the anastomosis. Clarifying language also defines and differentiates the extent of performance of the EUS examination versus the extent of the endoscopic procedure.
In addition to transmural drainage of pseudocyst previously described in code 43240, this code has been revised to clarify that the pseudocyst drainage procedure includes performance of endoscopic ultrasound, performance of transmural drainage and placement of stents to facilitate drainage.
Balloon Dilation of Esophagus
Balloon dilation code 43249 describes dilation of esophagus less than 30 mm diameter. Changes to this code now specify that code is reported for transendoscopic balloon dilation.
Other new codes for the EGD family include endoscopic mucosal resection, ultrasound-guided injection of celiac plexus/placement of fiducial markers, dilation of esophagus with balloon greater than 30 mm diameter, and stent placement with dilation over guide wire. The codes for control of bleeding, ablation, placement of stent and dilation of obstruction lesions have been revised.
Revisions to the ERCP family include clarification of the inclusion of sphincterotomy as an inherent component of a therapeutic procedure and addition of new codes to clarify removal of stent vs. removal and exchange of stent.
Code 43274, reported for removal of calculi from the biliary and pancreatic ducts has been revised to clarify that this code may be reported for removal of debris or calculi.
The complete CPT code descriptors and instructional information are now available in the CPT 2014 data files, with availability of the CPT 2014 books by Sept. 30, 2013. All changes will be implemented on Jan. 1, 2014. Look for the ACG, AGA and ASGE 2014 CPT Changes Update in October for a complete listing of gastroenterological coding changes.