Now, let's talk about something that is a little bit different. We're going to talk about proper documentation for advanced endoscopies. And we've already had several questions already regarding unlisted procedures, et cetera. So we're going to go through some of the more common advanced procedures and which includes some unlisted procedure codes and how to bill those, what needs to be included in our documentation. And more importantly, too, is when we submit an unlisted procedure to a payer, we want to make sure that we submit it correctly and that we get proper payment for those advanced procedures or unlisted procedures. All right, so some of these procedures are not unlisted. They have CPT codes established to them, but we typically see the advanced endoscopy providers perform these types of procedures. The first one we're going to talk about is endoscopic ultrasound. So since, and this has been since 2014, they revised the EOS documentation criteria prior to 2014, 43237 just said this, an EOS limited to the esophagus, okay, well, they had updated that and they say to include less than three areas of the GI tract and adjacent areas, okay. So what that means is your documentation should support that the provider examined all areas of the upper GI tract with the use of the ultrasound device, okay, if they are billing for the full EOS procedure, so 43259. Another big question we get is that third bullet that says when performing an EOS and a biopsy is done separate from that site, you can bill the biopsy, but you're going to modify that with a 59, okay. Diagnosis code is going to be different than why you're doing the EOS. You know, so if provider does an EOS, they also identify there's an area of erythema, gastritis, and they do a biopsy, that's separate, but the diagnosis for the biopsy is going to be the erythema or the gastritis, not, you know, why they're, you know, let's say a pancreatic cyst, okay, that would go to the EOS, right, so diagnosis codes, and we've been saying this pretty well all day, diagnosis codes are so important on claims and when you're billing for multiple procedures, making sure that you get the correct diagnosis code linked to support that technique. All right, so here's an example of an endoscopic ultrasound, so the indications are abnormal abdominal pelvic imaging scan, elevated liver enzymes, and right upper quadrant pain, so we had a prior cholecystectomy, and he presents for evaluation of a biliary obstruction, he had a recent MRI which revealed a dilated common bile duct, so after obtaining consent, the endoscope was passed under direct division, and then they go into the linear EOS was introduced through the mouth and advanced to the second portion of the duodenum, the esophagus, stomach, and duodenum were visualized endosonographically, that is what needs to be in your documentation if you are billing for the full EOS and not the limited, okay, so typically when we look at an endoscopy report that's an EOS, we typically see endoscopic findings and we see EOS or ultrasound findings, so the endoscopic findings, it says esophagus was normal, there was patchy erythema found in the gastric body and gastric antrum, so biopsies were taken with cold forceps, the examined duodenum was normal, on endosonographic findings, there was dilation in the common bile duct, it measured up to nine millimeters, there was, there appeared to be a distal common bile duct stricture, moderate hyperechoic material consistent with sludge was visualized endosonographically in the common bile duct possible stricture in the dilated, in the distal duct, there was no sign of significant endosonographic abnormality in the visualized portion of the liver, no masses were identified, pancreatic parenchymal abnormalities were noted in the entire pancreas, these consisted of hyperechoic foci, no lymphadenopathy seen, all right, so on that stomach biopsy, it showed antral mucosa with no significant abnormalities, there's no H. pylori, etc., so what do we bill here? Well, we're going to bill for the EOS, the full EOS, because remember, let's go back to that slide, that underlined portion supports 43259, billing for the full EOS component, and then the diagnosis codes are the indications, you can also include the dilated bile duct, etc., 43239 with a 59, so we have to modify that biopsy, because they are bundled on CCI edits, but the diagnosis code is going to be the erythema, or the, you know, it's erythema is what was found, and since biopsies appeared normal on the path, you kind of, it's, we call it the funny looking area diagnosis codes, so you're supporting why you did a biopsy, but it came back as nothing, so it's other disorders of the stomach and duodenum, okay, so both are billable, and one thing that I do want to comment on, let me go back to this, that underlined portion, if you're, if you have the ability to have like kind of a template in your endorider for your EOSs, and you're doing a full EOS, template that information in there, that the esophagus, stomach, and, because we know you see it on the way down, do you get direct details, you know, exact details, no, because you're going to go look at the abnormality that you went in to do, but you still have to have that verbiage in your endoscopy report, or you're billing the limited EOS. EMR, so Dr. Littenberg kind of hit on this one when we had that question regarding the EMR, so 45390 for colon with EMR, 43254 if you do an upper endoscopy with EMR, and then 45349 for flex sig with EMR, okay, so what does EMR include? So we're raising, so these are usually larger broad-based polyps, okay, so they're usually, they're flatter, they're laying on, you know, they're not a polyp on a stock that you can just, you know, snip off, so we have to inject, we have to inject them to raise them up, mark, demarcate the lesion, which isolate it, and then we use snare, banding, and other special devices to remove the tissue. You know, there's all kinds of different EMR kits, devices, and whatever out there. The biggest thing that I cannot stress enough to providers, if you are doing an EMR, the verbiage needs to be contained in your documentation. EMR performed on the following, or mucosal resection performed on XYZ, okay, so, and the reason I say that, remember the comment I made when I was talking about E&M, that auditors, payers, they don't necessarily have a GI expert background, okay, they're not going to look at your endoscopy report and go, oh, there was, there was an injection, they demarcated the, oh, yep, that's an EMR, they don't know that, okay, they're looking at the CPT code that says endoscopic mucosal resection, so that term needs to be in your endoscopy report, all right. A lot of times, um, you might treat the area, whether you APC it, you place clips or whatever to prevent post-polypectomy bleeding, that's all part of EMR, not separately billable. If biopsies of the same lesion is done, or the surrounding tissue, it's still considered part of the EMR, it's not a separate lesion at that point. Now, what happens if you do biopsy a separate lesion? Yeah, you can bill it, but it's a separate lesion, and we would modify the biopsy. If you do endoscopic ultrasound, that can be billed, as long as it's clinically warranted. This is something that I know Kathy brought up in the updates, and it has to do with payers that are denying the EMR when the patient's coming in for screening colonoscopy, they consider it a second step procedure. Okay, so sometimes we just have to send records to tell them, hey, you know, instead of bringing the patient back in again, we're going to just do it here. Um, and again, term EMR needs to be in your endoscopy report. Communication between coders and providers are essential for accuracy of claim, so if, if, if you have a coder that's unsure, they're like, well, you know what, this looks like an EMR, but he really doesn't say it, talk to the provider, have them do an attestation to the documentation that has that verbiage in there. So here's an example. So 74-year-old male presents for EMR of a complex rectopolyp. So that's typically the cases that we see is the patient coming back, we know, we know there was a polyp, you know, we often biopsy that polyp or whatever, and then bring them back for the EMR. Okay. Monitored anesthesia care was done, no complications. After informed consent, scope was passed under direct vision, monitored the patient, et cetera. Colonoscope was introduced through the anus and advanced to the cecum, identified by penile orifice and ileocecal valve. The colonoscopy was performed without difficulty. Patient tolerated well. Quality of prep was fair. The ileocecal valve, the penile orifice, and rectum were photographed. The perianal and digital rectal examinations were normal. Pertinent negatives include no palpable rectal lesions. Diverticula were found in the sigmoid colon. A four millimeter polyp was found in a hepatic flexure. The polyp was sessile. The polyp was removed with a cold snare. Resection and retrieval were complete. A 30 millimeter, so again, very big, found in the rectum. The polyp was sessile. The polyp was removed with an ORIS injection lift technique using hot snare. 10 cc's of ORIS was utilized for a lift. The polyp was removed with a piecemeal technique using a hot snare. Resection and retrieval were complete. APC was utilized on the edges to close the defect. After endoscopic mucosal resection, six clips were placed successfully. There was no bleeding at the end of the procedure. All right. So path diagnosis, the hepatic flexure polyp was a tubular adenoma. No high grade dysplasia. And same with the rectal polyp. It was a tubular adenoma as well. All right. So what do we report? We can build both techniques. Okay. We know we have the EMR 45390 with the 59 modifier. Okay. And then the snare. Ironically, ironically, when you look at CCI edits, the EMR is actually the bundled code when you're billing EMR and snare. Okay. But both are billable. You're going to link the appropriate diagnosis code to the technique that you build. Okay. All right. What about submucosal dissection? Okay. This is a little bit more invasive than an EMR. This typically takes a provider a long amount of time to complete the procedure. Okay. So this is more of a like an excision. Okay. Can involve advanced techniques to remove such as an endoscopic cautery knife to separate it from the underlying surfaces. So basically, this is a typically an open procedure, but we are doing it endoscopically. All right. So we have no CPT code for an ESD. Unlisted procedure and where you're at, whether it's colon, esophagus, stomach, and we give you the comparable RVUs. When we say comparable RVUs, when you try to bill for an unlisted procedure, the system does not know what dollar amount attached to it. Okay. So that's why we say look at the RVU value of a comparable code. All right. So if you get reimbursed, you know, $800 for 44110, okay, the RVUs, then you're going to create your fee based upon that, whether you do double, triple, whatever it is. Okay. At the end of the day, it doesn't matter how much, you know, money you put on there, the payer's going to pay what they think that you deserve. So it's so important to document, put it in lay terms what you're doing. But anyway, this is unlisted. Here's an example. So indication rectal, rectosigmoid colon carcinoma in situ found during previous screening. Sigmoidoscopy with full thickness resection. Okay. So a 10 millimeter polypoid lesion was found in the sigmoid. The lesion was sessile. Preparations were made for full thickness resection. The device was placed into the therapeutic endoscope. The lesion was then grasped into the cap of the clip and the clip was deployed over the entire lesion. The snare was then used to resect the lesion in a piecemeal fashion above the clip and retrieved with a suction via working channel. Resection and retrieval were complete. A slow ooze remained at the end of the procedure. For hemostasis, one clip was placed. There was no bleeding at the end of the procedure. Okay. Now estimate a blood loss impression. Okay. So they describe the procedure again and then recommendations. All right. So four, five, four, five, three, nine, nine, and then set up your fee. Okay. And then diagnosis would be D01.1 for carcinoma in situ of the rectosigmoid junction. Okay. One more thing I would add to this procedure, time. Okay. How much time did it take you to do this? So if I was looking at this on the payer end, I don't know that this is a hugely technically complicated procedure, but put it in writing. It took me an hour and a half to do this procedure and this was the complexity of it. Endoscopic pancreatic necrosectomy. Okay. I'm not going to describe everything that's involved, but this is done endoscopically and it's to puncture. You go through the wall of the stomach or duodenum to drain that tissue, remove it, et cetera. So again, we're dealing with an enlisted procedure in the pancreas 48999 and the RVU comparison 48105. I, it's still, I still can't believe we don't have a CPT code for this one. You know, we've got advanced endoscopy providers doing more and more and more pancreatic necrosectomies. So here's an example indications, abnormal, sorry, abnormal abdominal CT scan, pancreatic pseudocyst walled off necrosis here for evaluation of cystic gastrostomy. So then we've got consent, et cetera. Scope was advanced through the mouth to the second portion of the duodenum. Your endosonographic findings, esophagus, stomach, and duodenum were visualized endosonographically. A small amount of hyperechoic material consistent with sludge was visualized endosonographically in the common bile duct. The common bile duct was six millimeter in diameter. And then there was fluid collection noted in the head unicate process. There was large fluid collection noted around the posterior wall of the stomach, displacing the stomach and also the structures close by. This measured 114 by 67 in one dimension. This was larger than the dimensions mentioned. This was four millimeter from the gastric wall. A clear window was found with no intervening blood vessels. Color Doppler, color Doppler was used. The decision was made to create a cyst gastrostomy using the stent system. Once an appropriate position in the stomach was identified, the common wall between the stomach wall and the cyst were punctured under endosonographic guidance. The stent and electro electric cautery device was introduced through the working channel and advanced. The current was applied to the cautery tip and then used to increase in diameter of stoma. The device was advanced into the cyst. Stent was placed with flanges in close approximation to the walls of the cyst and the stomach through cyst gastrostomy. Then a TTS balloon was used to dilate the cyst gastrostomy track. So then you've got the findings. Okay. In the stomach, the stent was seen and cyst gastrostomy was entered and lavage was done with 500 ml of sterile water and suction. The necrosectomy was done with the snare and multiple passes were done. This was partially filled with black necrotic tissue that was pasty and adherent to the cyst wall. Necrosectomy was performed with a snare requiring numerous intubations of the cyst. Then two stents were placed into the walled off necrosis and additional cyst gastrostomy stents. Okay. So we've got two procedures here. We've got drainage of the pseudocyst, the cyst gastrostomy, which is 43240. So we have a CPT code for that one, but we also need to for the pancreatic necrosectomy, which is that unlisted procedure code. EUS with fiducial marker placement or injection of therapeutic substance. I think we typically use it more so for the therapeutic agent, like celiac plexus block, for example, with patients with chronic pain, et cetera. That is a code 43253. It includes radiologic guidance and only it is the most extensive procedure that you would bill. You know, any of the biopsies, the injections, placement of markers, that's all included. So here's an example. Chronic pancreatitis, celiac plexus block for pain secondary to chronic pancreatitis, epigastric abdominal pain, left upper quadrant abdominal pain. This is a 38 year old female who presents for celiac plexus block. MAC was given, no complications. After obtaining consent, the scope was passed to the second portion of the duodenum. The esophagus, stomach, and duodenum were visualized endosonographically. The upper EUS was accomplished without difficulty. The patient tolerated the procedure well. The linear EUS was introduced through the mouth and advanced to the second portion of the duodenum. So you've got normal esophagus, heidel hernia was present, examined duodenum was normal. On endosonographic findings, no significant abnormality in the bile duct, gallbladder, liver, no lymphadenopathy was seen. Pancreatic parenchymal abnormalities were noted in the pancreatic head. This was consistent with calcifications. Pancreatic parenchymal abnormalities were noted in the entire pancreas. The pancreatic duct had a predominantly branched endosonographic appearance, a torturous ectactic appearance, and had hyperechoic walls in the entire pancreas. Celiac plexus block was performed. The region of the celiac plexus and celiac ganglia was identified endosonographically with color doppler imaging using the takeoff of the celiac trunk from the anterior aspect of the aorta as the main anatomic landmark. Color doppler guidance was also used to confirm lack of significant vascular structures within the injection needle path. Using a transgastric approach, a 22-gauge needle was advanced to the area of the celiac plexus. Needle aspiration was performed prior to the injection to exclude entry into the blood vessel. A total of 10 ml, 0.25%, and 40 milligrams were injected into the celiac plexus block. The needle was then withdrawn. Okay, so very, very, very detailed on that celiac plexus block. You've got CPT 43253 and diagnosis codes. Endoscopic closure of fistulas. So we can close fistulas endoscopically as well, and those are also unlisted. And again, the unlisted procedure is depending upon where you're performing that. So whether it's the small intestine, the small intestine, stomach, colon, rectum, wherever. Okay, and then we've got your RVU comparison as well. EDGE. Okay, so this is an endoscopic ultrasound-assisted transgastric ERCP. All right, it is a novel technique developed to perform ERCP in a completely endoscopic fashion in Roux-en-Y patients. Because patients have undergone the Roux-en-Y, they have their intestines rearranged surgically for weight loss, a conventional ERCP is no longer possible. Currently, the standard of care is to perform a combined surgical endoscopic and endoscopic procedure to access the bile ducts. Endoscopists can now avoid the surgical part by utilizing the EUS to temporarily reverse a bypass using a special design stent to allow for the performance of a conventional ERCP. When the ERCP is complete, the stent is removed and the bypass anatomy is restored via endoscopic suturing. This is all performed completely from inside the body with an endoscope and can be performed on an outpatient basis. Crazy. Interesting, interesting procedure. But of course, we have no CPT code for it. So we're back to unlisted, RVU comparable to 43240. But if you end up doing, when you do the ERCP, your other ERCP techniques performed can be coded as well. PoEM, perioral endoscopic myotomy. It's used to treat achalasia. And we do have a code for this. This was actually new this past year. Okay. January 1st, 43497. TIF, the transoral incisionless funduplication. Okay. So it corrects the root cause of girth and we do have a CPT code of 43210. It includes esophagoscopy and obviously used on patients for severe girth. So it's a lot of these, a lot of these open or laparoscopic procedures can now be done endoscopically. And that's kind of what we're seeing. Chromoendoscopy. Okay. This is stains that are applied to the mucosal lining of the GI tract. Okay. And I'm not going to read all this to you, but it is a chemical application. So it's just considered component of standard endoscopy. But obviously we talked about modifier 22. If it takes you a lot longer to do this procedure, documentation of why and submission of modifier 22 may be appropriate. Okay. But remember, we have time thresholds in the values of our procedures. So make sure that it's not just, it's took me 15 minutes longer. That's not going to get you any extra money. This took me an hour longer. This took me 45 minutes longer than my normal procedure time. That may get you a little bit extra money. We've got optical chromoendoscopy is endo, sorry, endomicroscopy. So the physician views any abnormality of the mucosal lining using an endomicroscope that is attached to the esophagoscope. It's used laser light to magnify the cells of the mucosa in order to identify histopathology in real time. So basically it's just, it's lighting up, it's magnifying the lining. Okay. So we have 4, 3, 2, 0, 6 for esophagoscopy, 4, 3, 2, 5, 2 for the full EGD. And then we have ERCP 0397T and you would report that in addition to your ERCP code. So appropriate billing for unlisted procedures. Okay. Obviously if we have a CPT code, that's good. But if not, we're stuck with unlisted. So we've got a question. Which of the following documents would a payer need for maximum reimbursement of an unlisted procedure? Okay. So one of these choices, the operative report, the patient's last clinic note, letter of medical necessity and operative report or just letter of medical necessity. All right. Operative report came in second and you guys are right. You guys, this is a very, very smart audience. Letter of medical necessity and operative report is the best way for maximum reimbursement. Okay. You know, that letter of medical necessity is going to help explain to the payer why the patient's having this procedure done and, you know, kind of putting it in lay terms. All right. So appropriate billing for unlisted procedures. So in unique situations and advanced procedures that don't have a CPT code, we have to use an unlisted, payers will automatically deny any unlisted procedure code and request documentation. Okay. They don't know what to pay you until they look and see what you did. Most of these procedures are not elective. Okay. And will be done during initial endoscopy procedures. If these procedures are elective, pre-authorization eligibility are essential to coordinate billing between provider and payer. Don't just assume that the payer is going to pay you anything for some unusual procedure that you do. You definitely have to, you know, get your ducks in a row before you do these procedures. Be sure documentation, it's got to state complexity and time. Create a cover letter or letter of medical necessity and it should contain information as benefits of the endoscopy versus open, shortened hospital stay, outpatient stay, return to work, money is less as well, okay, than paying for a major open procedure that the patient has to be in the hospital for a week. Also, you can try to gather costs, costs of an open and an inpatient setting versus an outpatient or observation stay for the endoscopic procedure. Okay. So think about that. But most importantly, when you write those letters and when you document time and complexity, put it, put the information into where it's clearly understandable by the payer. That's what's going to get you paid money. If they see a note and they have no idea what you're doing, you might get a hundred bucks. So definitely keep that in mind. So claims. When you bill for an enlisted procedure code, you've got to put the precise procedure description in box 19. That's the free text field. Medicare will deny your claim without this information. The denial will read that the claim is unprocessable. When they say that, you have to do an error in logging adjustment and submit a new claim. So you're causing yourself more work if you don't get that description. Always wait for the denial to submit your cover letter and your documentation. Okay. Create a fee schedule that is appropriate for the procedure performed. Just don't pick the closest code you can find and bill that CPT code because you don't want to mess with unlisted procedures. If we continually bill for these unlisted advanced procedures, that helps us to potentially get a code in the future. All right. Other. There's others. Okay. So some of our enteroscopies that we bill for, enteroscopy with dilation, tattoo, balloon, snare, retrograde enteroscopy is also an enlisted procedure. So be aware of that as well. All right. Thank you.

advanced endoscopies

proper documentation

CPT codes

modifiers

billing

unlisted procedures

Medicare