All right, so we're going to kind of still talking about procedures, but we're going to kind of move this into advanced endoscopy and some reimbursement tips when you have to build those unlisted procedure codes. So we're going to talk about a whole lot of things, all right, in 30 minutes, we're going to talk about EUS, endoscopic ultrasound, EMR, a little bit on ESD, I've got a couple of examples, pancreatic necrosectomy, EUS with fiducial marker placement, fistula closures, the EDGE procedure, POEM, which is the perioral endoscopic myotomy, transoral incisional fun duplication, the TIF, chromoendoscopy, optical endomicroscopy, and then of course, ending that with proper documentation and claims processing for advanced procedures. All right, before we get started, we're going to test your knowledge again. So the question is, the provider performed an EMR of a polyp in the colon, what is the appropriate CPT code to bill? The first one is 453858 with an 8-1 to the snare and injection, an unlisted procedure, I have no idea, or 45390. Oh, we have got a smart group. 79% of you said 45390, which is the colonoscopy with EMR, and that is correct. We're going to talk a little bit about this in the presentation. So I've got an example of an EMR versus the snare and lift. I know when that EMR code came out several, it's been a few years now, there were some big confusion on documentation for, you know, how do you document it appropriately for the EMR versus when to know to bill the snare and the lift. So hopefully some clarifications there if you were still, you know, had some questions on it. So let's talk a little bit about endoscopic ultrasound. This code has been out for quite a while, and again, many of our advanced endoscopists will perform the EUS procedure. But one area that we like to clarify is the information that was published in 2014, and it was revisions to those descriptions for the EUS. So 43237, which it was revised to include less than three areas of the GI tract and adjacent structure. So, you know, it used to say limited to the esophagus. So if you only did an EUS evaluated the esophagus by EUS, then that would be your CPT code. Okay. But if now with those revisions, you must indicate that you examined all areas of the GI tract with the use of the ultrasound device to in order to bill that full EUS, 43259. Okay, I'm going to show you kind of some tips on making sure you've got that verbiage in your documentation. Also, let's talk a little bit about biopsy. So if you do an EUS and you have a separate biopsy, I'm not talking about an FNA, I'm talking about a separate endoscopic biopsy, you can bill both. Just make sure that it's, you've got a different diagnosis for the reason for biopsy, and it's done on a separate site. And we're going to modify that biopsy with a 59 or XS modifier. All right, so here's a clinical example of an EUS says indication abnormal pelvic imaging scan, elevated liver enzymes and right upper quadrant abdominal pain. So this is a 62 year old with a prior cholecystectomy presents for evaluation of biliary obstruction. And you get a recent MRI which revealed a dilated common bile duct. You've got the procedure description. Now I've got further down in this paragraph, I'm not going to read all this to you. But further down in that paragraph, it's got that the italicized verbiage says the esophagus, stomach and duodenum were visualized endosonographically. And I think that's really a good statement for you to have if you know like so say you're going into look at the bile ducts, you're looking at the pancreas, the pancreatic ducts. If you are looking at that, you're still going through and doing a visual of the esophagus stomach duodenum and just making sure that they've got normal appearance, there's nothing, you know, grossly abnormal about them. And again, making that statement will give you credit for that full EUS. So usually when you're looking at an EUS procedure note, there's two different findings. There's usually your endoscope findings and then there's your EUS findings. So on this one, endoscopic findings, the esophagus was normal. There was erythema in the gastric body, which biopsies were taken with cold forceps and the duodenum was normal. Now on endosonographic findings, you've got dilation in the common bile duct. There appeared to be a distal stricture. Moderate hyperechoic material consistent with sludge was visualized endosonographically in the common bile duct, possible stricture in the distal duct. There was no significant abnormality in the liver, no masses identified. Pancreatic parenchymal abnormalities were noted in the entire pancreas. No lymphadenopathy seen. So path diagnosis, okay, because remember we did a biopsy in the stomach. Antral mucosa with no significant histopathologic abnormalities, no H. pylori. All right, so billing for this. So if I'm looking at this report, I'm going to submit this on a claim. I'm going to give that provider credit for the full EUS 43259 and then the diagnosis codes and then the biopsy separate with the modifier. And again, we're going to reference the gastritis or the erythema, that erythema area that prompted us to do the biopsy. That diagnosis should be submitted with the biopsy. All right, let's talk a little bit about EMR, okay, endoscopic mucosal resection. And again, a lot of confusion when this CPT code came out. And a lot of it had to do with some of the endoriders that are out there that, you know, if you actually did a saline lift polypectomy, the computer would pick up the EMR code and then auditors on the payer side would review it and say this isn't an EMR and then they, you know, deny or whatever. And so I think one of the biggest things is like what is considered an EMR? Well, good question. It's up to the provider to determine whether, you know, whether you're doing an EMR or not. So it can include submucosal injections, snare, banding, or other special devices to remove the tissue. And as technology progresses and we have all these different tools to use, the description of an EMR is going to change as far as all the different techniques that could encompass an EMR. All right, so 45390 is your colonoscopy with EMR. 43254 is your upper endoscopy with EMR. And then 45349 is your sigmoidoscopy with EMR. All right. Typically an EMR is applied to a larger broad-based polyp that can involve a snare, a duet kit, cap assisted, anything to help facilitate the removal of the lesion. It can be used in a combination with a banding that creates a stalk. Hemostasis may be required by APC, clips, et cetera, but all of that is part of the EMR procedure. If biopsies are taken to the same area as the removal, that is not separately billable as well. If you do an EUS, you can report that separately if it's clinically warranted. Again, much more involved than just a simple saline lift and snare. But again, make sure that EMR verbiage is used. I can't stress that enough. That's probably the most important piece of information I'm going to tell you when you do EMRs is make sure that you're utilizing that verbiage, endoscopic mucosal resection. If you are a coder or a biller listening in and you have, you know, you get a report from your physician and you're just not sure, is this truly an EMR or is it something different, ask the provider. We want to make sure that we're billing correctly for your procedures. All right, so we have an example of an EMR. Indication, 74-year-old male presents for endoscopic mucosal resection of a complex rectal polyp. So MAC was given. And then you've got your procedure informed consent. The scope was passed to the CECM, et cetera. And then we'll get to the findings. A 4-millimeter polyp was found in the hepatic flexure. The polyp was sessile. The polyp was removed with a cold snare. Resection and retrieval were complete. Then we have another polyp, 30-millimeter polyp, in the rectum. The polyp was sessile. The polyp was removed with an Orize injection lift technique using a hot snare. 10 cc's of Orize was used for a lift. The polyp was removed with piecemeal technique using a hot snare. Resection and retrieval were complete. APC was utilized on the edges to close the defect after EMR. Six clips were placed. There was no bleeding at the end of the procedure. All right, PATH. PATH diagnosis comes through. So for the hepatic flexure polyp, it's a tubular adenoma, no high-grade dysplasia. And the rectal polyp was also a tubular adenoma. So how do we bill for this? Well, we're going to bill an EMR on that big old 30-millimeter polyp. That was a rectal polyp, so the diagnosis for the EMR would be D12.8. You can also bill the snare because, remember, the snare was done to a separate lesion. So you can bill both, 45385 for the transverse colon polyp, which was D12.3. Now, you might look at this and go, well, the EMR is the most extensive procedure. Why does that one take the 59 modifier? Well, that's how CCI edits are. If you look up, if you're familiar with CCI, CCI Correct Coding Initiative edits, it's published by Medicare. You can go in there. Get in there and look at it. And it tells you which procedure codes are bundled together. And then that column 2 is the procedure. If the procedure code is in column 2, that is the procedure that takes that 59 modifier. And if you look up a snare and an EMR together, the EMR actually takes the 59 modifier. But you still can bill for both as long as they're done on separate lesions. All right, so that's a true EMR. And remember, if you looked at that report, the provider used the term endoscopic mucosal resection was completed. All right, so that's probably key for your EMRs. Now, let's look at a saline lift polypectomy. So patient comes in for screening colonoscopy. The scope was introduced for the anus. It advanced to the cecum, identified by appendiceal orifice and ileocecal valve. One 15-millimeter polyp was found in the proximal ascending colon. The polyp was semi-pedunculated. The polyp was removed with a saline injection lift technique using a hot snare. All right, path came back as a tubular adenoma. What are we going to bill here? Well, 45385 because this was what? A screening converted to therapeutic PT modifier. Screening and the D12.2 diagnosis. We're also going to bill for that saline lift. I will tell you, these two codes, the 45385 and the 45381, are not considered bundled by CCI edits. However, the payer may not reimburse any extra for that saline lift since it was done to the same lesion. So clearly, big difference. That EMR involved a very big, large, broad-based polyp, multiple techniques to facilitate the removal, and then you've got your lift and cut. What about the submucosal dissection? Okay, this is a little bit more advanced, and typically even a lot of the advanced endoscopists don't perform this procedure. You usually see this in, like, a university teaching setting, et cetera. But you can bill it. All right, so this is a... It's similar to the open excision of a lesion, except you're doing it endoscopically. Known as an endoscopic cautery knife. So you are going, like, under that normal mucosal surface. It's a very complex procedure. It takes a long time to do. There is risks of perforation, et cetera, since you are doing a much more involved removal. Okay, you're basically cutting it out. Okay, so unlisted, there is no code for endoscop... There is no CPT code designated for the ESD. So if you're in the colon, 45399 is your unlisted code. Now, throughout this presentation, I give you RVU comparable codes. That doesn't mean you bill that code. What it means is when you bill an unlisted procedure code in your system, you're going to have a $0 attached to it. Because why? Well, the computer doesn't know how much it costs because it's unlisted. So you gather a fee comparable to the open technique done. Okay, 45399 comparable fee 44110. Then you've got your unlisted in the esophagus, unlisted of the stomach. So it depends on where that ESD was done. Endoscopic pancreatic necrosectomy. All right, so instruments are used through the endoscope to allow the endoscopist to puncture or enter directly through the wall of the stomach or duodenum inside the cavity. Okay, over the wire... Over a wire, the wall of the stomach or duodenum is dilated. The endoscope can be inserted from the stomach across the opening to the inside of the cavity, okay? There's a side-viewing scope like an ERCP can be used, which then replaced with a front-viewing upper endoscope. The endoscope is driven through the hole created inside the cavity in which different tools are used to facilitate removal of dead pancreatic necrotic tissue, okay? Again, another unlisted procedure, you're in the pancreas. So 48999, RVU comparable code 48105. Here's an example. Upper US cyst gastrostomy pancreatic necrosectomy. All right, generally anesthesia. So this is going to be a patient pretty well in the hospital, okay? Abnormal abdominal CT scan, pancreatic pseudocyst, pulled off necrosis here for evaluation of cyst gastrostomy. We've got procedure template endosonographic findings. The esophagus, stomach, and duodenum were visualized endosonographically. A small amount of hyperechoic material consistent with sludge was visualized in the common bile duct. And you've got more endosonographic findings. I'm not going to read all of this to you. It's just a description of that necrosectomy. All right, then you've got your endosonographic findings. And that fourth bullet down, that's where you have that description of the cyst gastrostomy, and then finally the stents placed and the walled-off necrosis was drained out, okay? So again, 45899 for the pancreatic necrosectomy. That should be 45399, sorry about that. 43240 can also be billed for the EUS, the drainage of the pseudocyst, 43240. There's also EUS for fiducial marker placement. Usually when we see an endoscopist do this, we're really doing like a celiac plexus block, 43253. This includes everything, so EUS, injection, placement of markers, all of it's all included in that same procedure code, right? Another example of the celiac plexus block, we've got a patient with chronic pancreatitis. Celiac plexus block for pain secondary to chronic pancreatitis, epigastric pain, left upper quadrant pain. MAC was used. Then you've got your procedure description endoscopic findings. Examined esophagus was normal. Heidel hernia was present. The examined duodenum was normal. Then you've got your description of endosotographic findings. And then that last bullet, that's where the celiac plexus block was performed. And the CBT code again on that is 43253. You've also got closure of fistula. So again, sometimes the advanced endoscopist will endoscopically close fistulas. And there is a description of what they do when they do the fistula closures. And we would report the enlisted procedure code depending upon where you're at in the stomach, small intestine, rectum, et cetera. And we do give you those RVU comparables as well. EDGE procedure, endoscopic ultrasound-assisted transgastric ERCP. Again, there is no CPT code available for the EDGE. So you're going to report 47999 RVU comparable to 43240. You can report your other ERCP techniques with this code. Perioral endoscopic myotomy POEM. So we do have a code effective January 1st for this procedure, which Kathy went into detail on that in the updates this morning. But as of right now, you would report 43999 for enlisted procedure of the stomach. And we do give you the RVU comparables to that as well. Then you've got your transoral incisionless funduplication, so TIF. 43210 is the CPT code. We do have a code, but of course, this is, again, considered an advanced procedure. It includes a diagnostic esophagoscopy used to treat patients with severe reflux. So a lot of these procedures that I'm talking about, used to do them open. We're moving these types of procedures into an endoscopic approach, which is what? It's less invasive for the patient, less complications. You've got chromoendoscopy. These are stains applied to the mucosal lining of the GI tract. Using a device known as a spray catheter can be inserted into the endoscope. So it is actually considered, it's a chemical application, so it's considered a component of your standard endoscopy. So there's not anything separate that you can bill for this. Optical endomicroscopy, so the physician views any abnormality of the mucosal lining using an endomicroscope that is attached to the esophagoscope. The endomicroscope uses laser's light to magnify the cells. So 43206 for the esophagoscopy, 43252 for the full EGD, and then we do have that temporary code 0397T for the ERCP. So appropriate billing for enlisted procedures. Again, I went through all of those procedures that actually had CPT codes, but the ones that didn't, those unlisteds, okay, you have to get an RVU comparable. So when you bill an enlisted procedure code, payers will automatically deny and request documentation, okay, because they don't know what you're doing. They don't know what you did. Most of these procedures are not elective, all right? Preauthorization and eligibility are essential when you do advanced endoscopy procedures. We get questions sometimes. It's like we performed this, you know, technically difficult unlisted procedure, and the payer didn't pay us for it. They said it's investigational or experimental or whatever. Well, that's what you need to do up front. Anything that is out of the ordinary for the regular endoscopist to do, you need to make sure, call, verify, and see if this is something that they will pay for. Be sure your documentation states complexity and time involved in any advanced procedure cases. Another thing that providers can do is create cover letters for your unlisted procedures. It should contain information to the benefits of your endoscopic versus your laparoscopic approach, patient-shortened outpatient stays, return to work, less money for the patient and the payer, and try to gather information as to cost if, you know, it ended up being like an open-type procedure. So payers want to know, does this benefit my patient? How does it benefit my patient? And again, less complications, less time out of work, et cetera. Now, when you bill for an enlisted procedure, you have to make sure that whoever's entering those charges uses that Box 19. It's that kind of that catch-all box you can free text, okay? And you have to put the procedure description in Box 19. Medicare will deny your claim without this information. The denial will read, claim is unprocessable, and it requires you to do an error and logging adjustment on the claim and resubmit a new one. So basically, it's going to cause you a lot of work if you don't get that procedure description on your claim form. Always wait for the denial to submit appropriate cover letters and documentation unless the payer is specific for those instructions. Otherwise, it just gets lost in their system, and you just have to redo it again. And again, create a fee schedule that is appropriate for that procedure performed. You can base this off RVUs for that comparable code. Some other unlisted procedures. So there's a lot of small bowel enteroscopies that we have CPT codes for, but we really don't have one for enteroscopy with dilation, enteroscopy with tattoo, balloon enteroscopy with snare, and how about the retrograde balloon enteroscopy? We don't have a code for that, so that, again, is 44799. All right, so that's kind of just a dive into advanced endoscopy. And again, very important to understand that we have to – sometimes if you're a big – and I'm going to just make this comment before I go on to my next talk. If you're in a big practice, you're in a big group, and you perform a good percentage of advanced procedures that causes you to bill a lot of unlisted procedures, it's good to maybe try to negotiate with your payers. Now, you're not going to be negotiating anything with Medicare, but at least with your major commercial payers, you could actually negotiate, and again, back to cover letters, even your physician meeting with the medical director, et cetera, to try to actually get an established fee for some of those procedures that you do, but it takes a lot of work on your end. But in the long run, it probably is beneficial.

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