Pa<ent presents to ER with rectal bleeding

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Howard Allison
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2012 Na'onal AAPC Conference GI Journey 2A Terry Fletcher Consul'ng, Inc. Speaker: Terry Fletcher BS, CPC, CCC, CEMS, CCS- P, CCS, CMSCS, CMC. www.terryfletcher.

1 2012 Na'onal AAPC Conference GI Journey 2A Terry Fletcher Consul'ng, Inc. Speaker: Terry Fletcher BS, CPC, CCC, CEMS, CCS- P, CCS, CMSCS, CMC (Do not duplicate without expressed wrigen consent of the author). Pa<ent presents to ER with rectal bleeding As coders we are story tellers. It is our job to paint a complete pa<ent health picture to the payer that will enable them to process payment to us on a clean claim, without ques<on. When a pa<ent presents for the ini<al encounter, we as specialty physicians are required to show medical necessity for the E/M service. Use ICD- 9 coding, chief complaints (abdominal pain, bleeding), indica<ons, and abnormal tests (i.e. iron deficient anemia labs) to support the E/M. If the E/M determines the need for a further diagnos<c workup, labs may be ordered or a colonoscopy may be the next step. A more defini<ve diagnosis (ICD- 9), such as GI bleed or intes<nal polyps, is now used. We are s<ll in the diagnos<c phase. AZer the colonoscopy is performed, an even more specific diagnosis is documented (benign or CA polyps, Chrohn s disease, or diver<culi<s) that could lead to possible colon resec<on or conserva<ve treatment for the disease. We have just now told a story to the payer that reflects medical necessity for all services performed and support for modifiers and quick reimbursement of our claim. Be an effec<ve Gastroenterology coder. TELL THE STORY! 2 1

Lower GI Anatomy Photo credit: www.smar<magebase.

3 ENDOSCOPY CODES GI Coding Range Type of Endoscopy Code Range Esophagoscopy Esophagogastroduodenoscopy (EGD) Proctosigmoidoscopy Sigmoidoscopy Colonoscopy Anoscopy ERCP Gastrostomy, Jejunostomy, etc., tubes Colonic Tubes misc Lower GI Endoscopy Procedures Reasons for Procedure It is used to examine, diagnose, and treat problems in your large intes<ne. The procedure is most ozen done for the following reasons: To determine the cause of abdominal pain, rectal bleeding, or a change in bowel habits To detect and treat colon cancer or colon polyps To obtain <ssue samples for tes<ng To stop intes<nal bleeding Monitor response to treatment if you have inflammatory bowel disease (IBD) AGE Appropriate for a Colo- rectal screening (i.e., 50+ male family history of colon cancer) 6 3

What is a Lower GI Endoscopy? Defini'on A colonoscopy is the visual exam of the rectum and colon (large intes'ne). The exam is done with a tool called a colonoscope.

4 What is a Lower GI Endoscopy? Defini'on A colonoscopy is the visual exam of the rectum and colon (large intes'ne). The exam is done with a tool called a colonoscope. The colonoscope is a flexible tube with a 'ny camera on the end. This instrument allows the doctor to view the inside of your rectum and colon. 7 Lower GI Endoscopy? Photo credit: 8 4

5 Pa'ent presents to office (or calls for an appointment) as a Screening (Age appropriate NO symptoms) SCREENING OR DIAGNOSTIC COLONOSCOPY QUESTIONAIRE GI 1. Have you had any severe, frequent changes in your bowel habits in the last 30 days? (diarrhea, cons<pa<on, or other). 2. Have you no<ced any bright red or brown blood in your stools? 3. Have you had any frequent cramping and/or abdominal pain and tenderness in the past 14 days that you cannot explain? 4. Do you have a family history (primary rela<ve- parent, sibling or child) that has had colon cancer? 9 Pa<ent presents to office as a Screening - part 2 SCREENING OR DIAGNOSTIC COLONOSCOPY QUESTIONAIRE GI 5. Are you experiencing any rectal pain that will not subside? 6. Are you Anemic? Or suffer from anemia? 7. Have you had a drop in your weight, without diet or increased exercise that would cause concern? 8. Do you feel any areas of weakness and fa<gue that is more then the norm with bowel changes? 9. Have you been diagnosed with IBD? (Inflammatory Bowel Disease?) 10. Are you on any blood thinners (Coumadin) or high risk medica<ons we should be aware of? 10 5

6 Pa<ent presents to office as a Screening - OPTIONS If any of these ques'ons were answered YES, then the pa'ent needs to be scheduled for an office visit (new or established) to determine the need for the Diagnos'c Colonoscopy and/or to be medically cleared for the Diagnos'c Colonoscopy (45378) or (G0105 Medicare). If all of these ques<ons received a NO response ask: Are you over 50 years old and your PCP referred you here for a Screening? According to AGA, if yes to the above ques'on, then you have a screening to schedule and no E/M. The pa'ent can be sent over to the hospital or endoscopy center for the procedure. This is referred to as Open Access GI screening. 11 Screening Colonoscopy Coding Pa<ent presents to the office with family history of colon cancer (mother), and is now 65 years old. PCP instructed pa<ent to get a screening colonscopy. Pa<ent has no complaints but takes Coumadin as prescribed by his cardiologist. A new pa<ent E/M is coded: DX: V16.0, V

7 Screening Colonoscopy Coding Procedure Pa'ent: Edward Gray Date of Procedure: 2/11/2012 Pre- op DX: Family History of Colon Cancer Post- op DX: Screening Colonoscopy with incidental diver'cula Indica'on: Edward is a 65- year old male who is on Medicare. Edward s mother had colon cancer. He is asypmtoma<c but a screening colonoscopy was advised due to his strong family history. Procedure: The pa<ent was counseled regarding indica<ons, technique, poten<al complica<ons and alterna<ves to colonoscopy. AZer consents and adequate seda<on achieved, he was kept in the lez lateral posi<on and the Olympus video colonoscope was passed anally. There was no perianal disease. The rectum was normal. The sigmoid revealed a diver<cula. The descending colon and transverse colon were normal. Examina<on was completed to the cecum. AZerwards the scope was withdrawn, inspec<ng mucosal surfaces on withdrawl. No abnormali<es of any were seen. The pa<ent tolerated the procedure well. Discussion: Edward s colonoscopy was normal except for diver<cula. This was incidental, no treatment needed. Reassure with an an<cipated 5 year follow up would be suggested. Code(s): G OVERVIEW OF GENERAL GUIDELINES FOR ENDOSCOPIC PROCEDURES The following specific ac<vi<es can be employed during the endoscopic procedure, along with the CPT code(s) used to describe the ac<vity: Biopsy If the same lesion is biopsied and subsequently removed during the same opera<ve session, only the code for the removal of the lesion would be reported. If one lesion is biopsied and a separate lesion is removed during the same session, it would be appropriate to report a code for the biopsy of one lesion and an addi<onal code for the removal of the separate lesion. The use of a modifier (e.g. 51 or 59) is essen<al when a biopsy for one lesion is performed and removal of a separate lesion by a different technique. The modifier is added to the lower valued procedure. 14 7

8 OVERVIEW OF GENERAL GUIDELINES FOR ENDOSCOPIC PROCEDURES, cont d Dila<on Hot biopsy or bipolar cautery treatment Abla<on of lesion not amenable to treatment by hot biopsy, bipolar treatment, or snare (i.e. laser) If the pa<ent presents for a screening, but there is an abnormality found and the procedure ends up being diagnos<c, append the modifier - PT to the CPT code to allow the payer to con<nue to waive the deduc<ble under the screening guidelines (new in 2011). Removal of foreign body Control of bleeding, any method There are several endoscopic procedures listed that deal with endoscopic control of bleeding by any method. These codes are intended to be used when treatment is required to control bleeding that occurs spontaneously or as a result of trauma<c injury and not as a result of another type of opera<ve interven<on. 15 Sigmoidoscopy Sigmoidoscopy The examina<on of the en<re rectum and sigmoid colon; may include examina<on of a por<on of the descending colon are used to report sigmoidoscopies The guidelines used for endoscopies apply to sigmoidoscopies 16 8

9 Colonoscopy COLONOSCOPY Colonoscopy describes an endoscopy in which a colonoscope is inserted into the anus and moved through the colon proximal to (past) the splenic flexure to visualize the lumen of the rectum and colon. Code are used to report colonoscopies. Colonoscopy is the examina'on of the en're colon from rectum to the cecum and may include the examina'on of the terminal ileum. The guidelines for endoscopy also pertain to colonoscopies. As indicated in the endoscopy guidelines, an incomplete colonoscopy, with full prepara'on for the colonoscopy, should be reported with the - 52 modifier for reduced services. Incomplete Colonoscopy: The inability to extend beyond the splenic flexure is billed and paid using colonoscopy code with modifier - 53 (This is typically due to poor prep of the pa'ent: Dx V64.3 is preferred). *Referenced CPT 2012 p Colonoscopy Coding Example #1: Physician performed a colonoscopy by snare in the ascending colon and an abla=on of a 4mm lesion in the sigmoid colon, and a biopsy of a 3cm lesion in the cecum. Codes: 45383, , **Always list the highest valued procedure first and then in descending value order add each additional endoscopic procedure that may be bundled with the modifier. 18 9

10 Colonoscopy Coding Example #2: Example: Pa2ent presents for a colonoscopy by snare of a polyp in the Sigmoid Colon (tabooing india ink used to lie this lesion because it was flat on the surface), and biopsy of the ascending colon. Codes: 45385, , **Always list the highest valued procedure first and then in descending value order add each additional endoscopic procedure that may be bundled with the modifier. 19 UPPER GI ENDOSCOPY 20 10

11 Upper GI Endoscopy What problems can upper GI endoscopy detect? ulcers abnormal growths precancerous condi<ons bowel obstruc<on inflamma<on hiatal hernia 21 Upper GI Endoscopy When is upper GI endoscopy used? Upper GI endoscopy can be used to determine the cause of: abdominal pain nausea vomi<ng swallowing difficul<es gastric reflux unexplained weight loss anemia bleeding in the upper GI tract Upper GI endoscopy can be used to remove stuck objects, including food, and to treat condi<ons such as bleeding ulcers. It can also be used to biopsy <ssue in the upper GI tract. During a biopsy, a small piece of <ssue is removed for later examina<on with a microscope

What is upper gastrointes'nal (GI) endoscopy? Upper GI endoscopy is a procedure that uses a lighted, flexible endoscope to see inside the upper GI tract.

12 What is upper gastrointes'nal (GI) endoscopy? Upper GI endoscopy is a procedure that uses a lighted, flexible endoscope to see inside the upper GI tract. The upper GI tract includes the esophagus, stomach, and duodenum (the first part of the small intes'ne). The bile ducts carry bile from the liver to the duodenum. The pancrea<c ducts carry pancrea<c juice from the pancreas to the duodenum. 23 EGD Esophagogastroduodenoscopy EGD Esophagogastroduodenoscopy describes a procedure in which the pyloric channel is traversed with the endoscope (Upper GI endoscopy) ( ) Coding an EGD that involves Helicobacter Pylori There are a number of commercial kits designed to detect the presence of urease produced by H pylori: They typically involve obtaining a <ssue biopsy via the endoscope The appropriate way to report the EGD por<on of the procedure is with is EGD w/biopsy 24 12

EGD w/peg tube placement EGD with PEG tube placement: 43246 is used to report percutaneous endoscopic gastrostomy (PEG) tube placement.

13 EGD w/peg tube placement EGD with PEG tube placement: is used to report percutaneous endoscopic gastrostomy (PEG) tube placement. (Feeding Tube) Percutaneous endoscopic gastrostomy (PEG) is a method of placing a tube into the stomach percutaneously, aided by endoscopy When a PEG tube is placed by 2 physicians, each physician reports code with the - 62 modifier appended Both physicians MUST dictate his/her own report The report must reflect medical necessity for having 2 physicians for the procedure Each physician will charge 125% of the MCR fee schedule and each will be reimbursed 1/2 of the allowed amount. Image courtesy of Wikimedia Commons. 25 ERCP (Endoscopic Retrograde Cholangiopancreatography) What is ERCP? Endoscopic retrograde cholangiopancreatography is a procedure that combines upper gastrointes<nal (GI) endoscopy and X- rays to treat problems of the bile and pancrea<c ducts. ERCP is also used to diagnose problems, but the availability of non- invasive tests such as magne<c resonance cholangiography has allowed ERCP to be used primarily for cases in which it is expected that treatment will be delivered during the procedure 26 13

14 ERCP When is ERCP used? ERCP is used when it is suspected a person s bile or pancrea<c ducts may be narrowed or blocked due to tumors gallstones that form in the gallbladder and become stuck in the ducts inflamma<on due to trauma or illness, such as pancrea<<s inflamma<on of the pancreas infec<on valves in the ducts, called sphincters, that won t open properly scarring of the ducts, called sclerosis pseudocysts accumula<ons of fluid and <ssue debris 27 ERCP CODING SCENARIOS Parent code and describes diagnos<c ERCP The common bile duct is cannulated, dye injected, and the biliary tree is visualized. The collec<on of specimens by brushing or washing is included Code only indicates 1 duct. If more then one duct is stented, each can be reported separately with the appropriate - 76, - 59 modifier. Code only indicates 1 tube or stent. If more then one tube or stent is changed or removed, this code can reported again with the appropriate modifier. Code Includes one or more dila<ons. If radiological supervision and interpreta<on is performed at the <me of the dila<on, code or can be reported separately if documented New for 2009, Add- on code: Endo cannula<on of papilla w/direct visualiza<on of common bile duct(s) and/or pancrea<c duct(s). List in addi<on to the major procedure (SPY GLASS). ERCP- is considered to be one technique. When mul<ple procedures by ERCP are provided the - 51 modifier should be used. When reflec<ng a dis<nct procedural service (other then the ERCP at the same session) there is no modifier needed on the lower valued procedure because they are typically not bundled. CODING Example: ERCP with stent placement into the pancrea<c duct and ERCP w/ sphincterotomy: 43268,

15 Mul<ple Endoscopy Rules MULTIPLE ENDOSCOPY POLICY: The mul<ple endoscopy policy for Medicare went into effect April 1, 1993 and is s<ll current. This policy can be found in the MCM sec<on and states: Mul2ple Endoscopies for mul2ple endoscopic procedures, use the full value of the highest valued endoscopy plus the difference between the next highest and the base endoscopy (the parent code). For example, in the course of performing fiberop2c colonoscopy (code 45378), a physician performs a biopsy (code 45380) and removes a polyp by snare (45385). Both codes contain the value of the base endoscopy, code Use the actual value of the code plus the difference between and to figure your reimbursement. The endoscopic base codes are listed in the MFSDB C.12. Conscious Seda'on: When anesthesia is provided by the physician performing the primary service, the anesthesia services are included in the primary procedure (CMS Global Surgery Policy). If it is medically necessary for a separate provider (anesthesiologist/anesthe'st) to provide the anesthesia services (e.g. monitored anesthesia care), a separate service may be reported by that provider. AMA s CPT book has also included a symbol in front of a code to reflect that conscious seda=on is included in that service. 29 Coding Tips for Endoscopy Reports - A Make sure that there is a pre- opera<ve and post- opera<ve diagnosis. Even if the endoscopy is nega<ve, go back to the original reason for the procedure as the diagnosis for the endoscopy. Be specific as to how the biopsy/polypectomy was performed. The phrase mul<ple polypectomies does not give enough informa<on to submit a claim. LOCATION, LOCATION, LOCATION. To get paid for the different techniques in different sites within the intes<ne, the loca<on of the lesion is essen<al to apply modifier If a Clo- test was done, this is billed/considered a biopsy. Make sure that this is men<oned in the report. Too ozen this is only in the path report. Wait! for the pathology report before assigning a diagnosis code if you can because neoplasms of uncertain behavior does not mean that the area looks suspicious, it means that there is atypia or dysplasia. Suspect Crohn s disease does not equal Crohn s. Code what you know, NOT what you don t. If 25 biopsies were taken during the session, make sure to also add how much addi<onal <me, work, effort was involved. There may be support for a - 22 modifier, if documented. Codes that describe biopsy(s) should only be reported once, regardless of the number of biopsies performed. EGD and Colonoscopies performed at the same session do not need a - 59 modifier on either procedure because they are not bundled together

16 Coding Tips for Endoscopy Reports - B Abla<on can be accomplished by argon plasma coagula<on (APC) and can be used on sessile polyps, AVMs, or other suspicious areas within the GI tract. If the intent of a colonoscopy was for screening and a polyp or lesion is found and treatment is done, the colonoscopy is billed as a surgical procedure and 2 dx s should be used. Example: V76.51 Screening for Colon Cancer Polyp Discuss Screening: Make sure you understand Open Access, no pre- screening OV, and DEDC for diagnos'c vs. screening 2011 MODIFIER - PT. Screening presenta'on converted to Diagnos'c Procedure. Medicare Deduc'ble WAIVED. Anemia unspecified (285.9) is not covered by most Medicare payers for colonoscopy and/or upper GI endoscopy. Be specific as to iron deficiency anemia substan<ated by iron studies. This needs to be in the report (280.0 or 280.9). Submucosal Inj (india ink/tauooing) is NOT Bundled into a Lower GI endoscopy, but IS bundled for an Upper GI endo. 31 Other Upper GI op'ons- New Technology What type of diseases can be diagnosed with Capsule Endoscopy? Capsule endoscopy con<nues to improve technically. It has revolu<onized diagnosis by providing a sensi<ve (able to iden<fy subtle abnormali<es) and simple (non- invasive) means of examining the inside of the small intes<ne. Some common examples of small intes<ne diseases diagnosed by capsule endoscopy include: Angiodysplasias (collec<ons of small blood vessels located just beneath the inner intes<nal lining that can bleed intermiuently and cause anemia) Small intes<nal tumors such as lymphoma, carcinoid tumor, and small intes<nal cancer Crohn's disease of the small intes<ne 32 16

Capsule Endoscopy What is capsule endoscopy? Capsule endoscopy is a technology that uses a swallowed video capsule to take photographs of the inside of the esophagus, stomach, and small intes<ne.

17 Capsule Endoscopy What is capsule endoscopy? Capsule endoscopy is a technology that uses a swallowed video capsule to take photographs of the inside of the esophagus, stomach, and small intes<ne. For capsule endoscopy, the intes<nes are first cleared of residual food and bacterial debris with the use of laxa<ves and/or purges very similar to the laxa<ves and purges used before colonoscopy. A large capsule (larger than the largest pill) is swallowed by the pa<ent. The capsule contains one or two video chips (cameras), a light bulb, a bauery, and a radio transmiuer. As the capsule travels through the esophagus, stomach, and small intes<ne, it takes photographs rapidly. The photographs are transmiued by the radio transmiuer to a small receiver that is worn on the waist of the pa<ent who is undergoing the capsule endoscopy. At the end of the procedure, approximately 24 hours later, the photographs are downloaded from the receiver into a computer, and the images are reviewed by a physician. The capsule is passed by the pa<ent into the toilet and flushed away. 33 Misc. GI Services IRC: What Is Infrared Coagula'on? (Hemorrhoids) Infrared Coagula<on (IRC) is the most widely used office treatment for hemorrhoids and is preferred over other methods because it is fast, well- tolerated by pa<ents, and virtually problem- free. A small probe contacts the area above the hemorrhoid, exposing the <ssue to a burst of infrared light for about one second. This coagulates the veins above the hemorrhoid, causing it to shrink and recede. The pa<ent may feel a sensa<on of heat very briefly, but it is generally not painful. Anesthe<c is usually not required. BRAVO PROCEDURE: (GERD/GE REflux) How does the Bravo esophageal ph test work? A small capsule, about the size of a gel cap, is temporarily auached to the wall of the esophagus during an upper endoscopy. The capsule measures ph levels in the esophagus and transmits readings by radio telecommunica<ons to a receiver (about the size of a pager) worn on your belt or waistband. The receiver has several buuons on it that you will press to record symptoms of GERD such as heartburn (the nurse will tell you what symptoms to record). You will be asked to maintain a diary to record certain events such as when you start and stop ea<ng and drinking, when you lie down, and when you get back up. This will be explained by the nurse. Many pa<ents have complained of pain las<ng for over a week

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