2015 Procedural Reimbursement Guide for Endoscopy

Transcription

1 2015 Procedural Reimbursement Guide for Endoscopy

2 THIS PROCEDURAL REIMBURSEMENT GUIDE, FOR SELECT ENDOSCOPY PROCEDURES, provides coding and reimbursement information for physicians and facilities. The Medicare payment amounts shown are national average payments. Actual reimbursement will vary for each provider and institution based on geographic differences in costs, hospital teaching status, and proportion of low-income patients. DESCRIPTION OF PAYMENT METHODS PHYSICIAN BILLING AND PAYMENT: Medicare and most other insurers typically reimburse physicians based on fee schedules tied to CODES. CPT Codes are published by the American Medical Association and are used to report medical services and procedures performed by or under the direction of physicians. HOSPITAL OUTPATIENT BILLING AND PAYMENT: Medicare reimburses hospitals for outpatient stays (typically stays of less than 24 hours) under AMBULATORY PAYMENT CLASSIFICATION GROUPS (APCs). Medicare assigns a procedure to an APC based on the billed CPT Code. s may receive separate APC payments for each procedure done during the same outpatient visit. Many APCs are subject to reduced payment when multiple procedures are performed on the same day. In most cases, the highest valued procedure is paid at 100% and all other procedures are subject to a 50% payment reduction. HOSPITAL INPATIENT BILLING AND PAYMENT: Medicare reimburses hospital inpatient procedures based on the MEDICARE SEVERITY DIAGNOSIS RELATED GROUP (MS-DRG). The MS-DRG is a system of classifying patients based on their diagnoses and the procedures performed during their hospital stay. MS DRGs closely calibrate payment to the severity of a patient s illness. One single MS-DRG payment is intended to cover all hospital costs associated with treating an individual during his or her hospital stay, with the exception of professional (e.g., physician charges associated with performing medical procedures). Private payers may also use MS-DRG based systems or other payer-specific system to pay hospitals for providing inpatient services. Effective October 1, 2013, Medicare implemented two-midnight stay guidance. Inpatient admittance is presumed to be appropriate if a physician expects a beneficiary s surgical procedure, diagnostic test or other treatment to require a stay in the hospital lasting at least two midnights, and admits the beneficiary to the hospital based on that expectation. Documentation in the medical record must support a reasonable expectation of the need for the beneficiary to require a medically necessary stay lasting at least two midnights. If the inpatient admission lasts fewer than two midnights due to an unforeseen circumstance this also must be clearly documented in the medical record. FREE-STANDING CLINIC/AMBULATORY SURGICAL CENTER BILLING AND PAYMENT: Many procedures are performed outside of the hospital in free-standing clinics. Payments made to free-standing clinics from private insurers depend on the contract the clinic has with the payer. Medicare payments to free-standing clinics are determined in part, by the licensing status of the clinic. If a free-standing clinic is licensed by Medicare as an AMBULATORY SURGICAL CENTER () it is eligible to be reimbursed for select procedures provided in this setting. Not all procedures that Medicare covers in the hospital setting are eligible for payment in s. Medicare has approved over 3,000 procedures (as defined by CPT Code), for which it will pay the a facility fee. CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Effective: 1-JAN-2015 Expires: 31-DEC-2015 ENDO AF DEC2014 2

3 THIS GUIDE, FOR SELECT ENDOSCOPY PROCEDURES, PROVIDES CODING AND REIMBURSEMENT INFORMATION FOR PHYSICIANS AND FACILITIES. THE CODES INCLUDED IN THIS GUIDE ARE INTENDED TO REPRESENT TYPICAL ENDOSCOPY PROCEDURES WHERE THERE IS: 1) At least one device approved or cleared by the U.S. Food and Drug Administration (FDA) for use in the listed procedure; and 2) Specific procedural coding guidance provided by a recognized coding or reimbursement authority such as the American Medical Association (AMA) or The Centers for Medicare and Medicaid Services (CMS). This guide is in no way intended to promote the off label use of medical devices. THE MEDICARE REIMBURSEMENT AMOUNTS SHOWN ARE CURRENTLY PUBLISHED NATIONAL AVERAGE PAYMENTS. Actual reimbursement will vary for each provider and institution for a variety of reasons including geographic difference in labor and non-labor costs, hospital teaching status, and/or proportion of low-income patients. On average, private payers pay significantly more than Medicare. 8 Please feel free to contact the Boston Scientific reimbursement department if you have any questions. Rates referenced in this guide do not reflect Sequestration; automatic reductions in federal spending that will result in a 2% across-the-board reduction to ALL Medicare rates as of January 1, You can find reimbursement updates on our website: Health economic and reimbursement information provided by Boston Scientific Corporation is gathered from third-party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules and policies. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice. Boston Scientific encourages providers to submit accurate and appropriate claims for services. It is always the provider s responsibility to determine medical necessity, the proper site for delivery of any services and to submit appropriate codes, charges, and modifies for services that are rendered. Boston Scientific recommends that you consults with your payers, reimbursements specialists and/or legal counsel regarding coding, coverage and reimbursement matters. Boston Scientific does not promote the use of its products outside their FDA-approved label. Effective: 1-JAN-2015 Expires: 31-DEC-2015 ENDO AF DEC2014 3

4 Biliary Procedural Reimbursement Guide - Select Endoscopy Procedures RVUs Physician,2 3 Code 1 Code Description Work Office In- Diagnostic Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) $351 $351 $1,952 $1,071 Therapeutic Endoscopic retrograde cholangiopancreatography (ERCP); with biopsy, single or multiple Endoscopic retrograde cholangiopancreatography (ERCP); with sphincterotomy/papillotomy Endoscopic retrograde cholangiopancreatography (ERCP); with pressure measurement of sphincter of Oddi Endoscopic retrograde cholangiopancreatography (ERCP); with removal of calculi/debris from biliary/pancreatic duct(s) Endoscopic retrograde cholangiopancreatography (ERCP); with destruction of calculi, any method (eg, mechanical, electrohydraulic, lithotripsy) Endoscopic retrograde cholangiopancreatography (ERCP); with transendoscopic balloon dilation of biliary/pancreatic duct(s) or of ampulla (sphincteroplasty), including sphincterotomy, when performed, each duct Endoscopic retrograde cholangiopancreatography (ERCP); with ablation of tumor(s), polyp(s), or other lesion(s), including pre- and post-dilation and guide wire passage, when performed $368 $368 $1,952 $1, $388 $388 $1,952 $1, $389 $389 $1,952 $1, $395 $395 $1,952 $1, $469 $469 $1,952 $1, $410 $410 $1,952 $1, $469 $469 $1,952 $1,071 Stenting Endoscopic retrograde cholangiopancreatography (ERCP); with placement of endoscopic stent into biliary or pancreatic duct, including pre- and postdilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent Endoscopic retrograde cholangiopancreatography (ERCP); with removal of foreign body(s) or stent(s) from biliary/pancreatic duct(s) Endoscopic retrograde cholangiopancreatography (ERCP); with removal and exchange of stent(s), biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent exchanged $501 $501 $3,174 $1, $408 $408 $1,952 $1, $521 $521 $3,174 $1,313 Inpatient Coding Inpatient Medicare Payment Possible ICD-9- CM Procedure Codes Code Description MS- DRG Description Inpatient Medicare National Average Payment Endoscopic retrograde cholangiopancreatography (ERCP) Endoscopic retrograde cholangiography (ERC) Other closed (endoscopic) biopsy of biliary duct or sphincter of Oddi 435 Malignancy of hepatobiliary system or pancreas with Major Complication or Comorbidity (MCC 5 ) $10, Malignancy of hepatobiliary system or pancreas with Complication or Comorbidity (CC 5 ) $6, Malignancy of hepatobiliary system or pancreas without CC/MCC $5, Disorders of pancreas except malignancy with MCC 5 $9, Disorders of pancreas except malignancy with CC 5 $5, Disorders of pancreas except malignancy without CC/MCC $3, Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis with MCC 5 $11, Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis with CC 5 $5, Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis without CC/MCC $3, Disorders of the biliary tract with MCC 5 $9, Disorders of the biliary tract with CC 5 $6, Disorders of the biliary tract without CC/MCC $4,439 See important information about the uses and limitations of this document on pages 2 and 3 ENDO AF DEC2014 4

5 Biopsy Procedural Reimbursement Guide - Select Endoscopy Procedures RVUs Physician,2 3 Code 1 Code Description Work Office In- Cold Biopsy Esophagoscopy, flexible, transoral; with biopsy, single or multiple $372 $115 $745 $ Esophagoscopy, rigid, transoral; with biopsy, single or multiple $176 $176 $1,064 $ Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple Endoscopic retrograde cholangiopancreatography (ERCP); with biopsy, single or multiple Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with biopsy, single or multiple Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with biopsy, single or multiple $410 $153 $745 $ $368 $368 $1,952 $1, $176 $176 $852 $ $326 $326 $1,249 $ Ileoscopy, through stoma; with biopsy, single or multiple $83 $83 $852 $ Endoscopic evaluation of small intestinal pouch (eg, Kock pouch, ileal reservoir [S or J]); with biopsy, single or multiple $361 $131 $790 $ Colonoscopy through stoma; with biopsy, single or multiple $403 $189 $790 $ Proctosigmoidoscopy, rigid; with biopsy, single or multiple $200 $82 $827 $ Sigmoidoscopy, flexible; with biopsy, single or multiple $166 $77 $494 $ Colonoscopy, flexible; with biopsy, single or multiple $471 $265 $790 $433 Hot Biopsy Esophagoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps $430 $149 $1,914 $1, $469 $187 $1,064 $ $195 $195 $1,249 $ $448 $225 $790 $ $225 $93 $827 $ $302 $113 $494 $ $472 $277 $790 $433 Inpatient Coding and Medicare Payment Inpatient payment information not shown because the biopsy procedure will rarely, if ever, be the primary reason for a hospital admission. See important information about the uses and limitations of this document on pages 2 and 3 ENDO AF DEC2014 5

6 Dilation Procedural Reimbursement Guide - Select Endoscopy Procedures Code 1 Code Description Work Office Balloon In Esophagoscopy, rigid, transoral; with balloon dilation (less than $193 $193 $1,064 $584 mm diameter) Esophagoscopy, flexible, transoral; with dilation of esophagus with balloon $210 $210 $1,064 $584 (30 mm diameter or larger) (includes fluoroscopic guidance, when performed) Esophagoscopy, flexible, transoral; with transendoscopic balloon dilation $1,162 $131 $1,064 $584 (less than 30 mm diameter) Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus $247 $247 $1,064 $584 with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed) Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic $1,109 $170 $1,064 $584 balloon dilation of esophagus (less than 30 mm diameter) Ileoscopy, through stoma; with transendoscopic balloon dilation $852 $ Sigmoidoscopy, flexible; with transendoscopic balloon dilation $496 $119 $827 $ Colonoscopy, flexible; with transendoscopic balloon dilation $678 $272 $790 $ Colonoscopy through stoma; with transendoscopic balloon dilation $790 $433 Balloon or Rigid RVUs Physician, Esophagoscopy, rigid, transoral; with insertion of guide wire followed by $204 $204 $1,064 $584 dilation over guide wire Esophagoscopy, flexible, transoral; with dilation of esophagus, by balloon or $1,264 $281 $1,064 $584 dilator, retrograde (includes fluoroscopic guidance, when performed) Esophagoscopy, flexible, transoral; with insertion of guide wire followed by $390 $144 $1,064 $584 passage of dilator(s) over guide wire Esophagogastroduodenoscopy, flexible, transoral; with dilation of gastric/ $633 $193 $1,064 $584 duodenal stricture(s) (eg, balloon, bougie) Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire $423 $184 $745 $409 followed by passage of dilator(s) through esophagus over guide wire Proctosigmoidoscopy, rigid; with dilation (eg, balloon, guide wire, bougie) $986 $96 $827 $454 Inpatient Coding and Medicare Payment Inpatient payment information not shown because the dilation procedure will rarely, if ever, be the primary reason for a hospital admission. See important information about the uses and limitations of this document on pages 2 and 3 ENDO AF DEC2014 6

7 Enteral Feeding Procedural Reimbursement Guide Select Endoscopy Procedures RVUs Physician,2 3 Code 1 Code Description Work Office In- Gastrostomy Tube Initial Placement Esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report $218 $218 $1,064 $ $1,058 $232 $1,064 $584 Gastrostomy Tube Replacement/Reposition Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance Replacement of gastrostomy or cecostomy (or other colonic) tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Repositioning of a naso- or oro-gastric feeding tube, through the duodenum for enteric nutrition $500 $49 $195 $ $678 $70 $488 $ $120 $107 $745 $409 Jejunostomy Tube Replacement of gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Conversion of gastrostomy tube to gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with conversion of percutaneous gastrostomy tube to percutaneous jejunostomy tube Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report $915 $147 $488 $ $1,017 $170 $1,064 $ $210 $210 $1,249 $ $1,058 $232 $1,064 $584 Other Procedures Mechanical removal of obstructive material from gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, any method, under fluoroscopic guidance including contrast injection(s), if performed, image documentation and report $745 $50 $488 $268 Inpatient Coding and Medicare Payment Inpatient payment information not shown because the enteral feeding procedure will rarely, if ever, be the primary reason for a hospital admission. See important information about the uses and limitations of this document on pages 2 and 3 ENDO AF DEC2014 7

8 Hemostasis Procedural Reimbursement Guide - Select Endoscopy Procedures RVUs Physician,2 3 Code 1 Code Description Work Office In- Control of Bleeding Esophagoscopy, flexible, transoral; with control of bleeding, any method $405 $182 $1,064 $ Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) $443 $221 $1,064 $ $263 $263 $1,249 $ $418 $418 $1,249 $ Colonoscopy through stoma; with control of bleeding, any method $508 $257 $790 $ Sigmoidoscopy, flexible; with control of bleeding, any method $167 $167 $827 $ Colonoscopy, flexible; with control of bleeding, any method $612 $336 $790 $433 Ligation Esophagoscopy, flexible, transoral; with band ligation of esophageal varices $156 $156 $1,064 $ Esophagogastroduodenoscopy, flexible, transoral; with band ligation of esophageal/gastric varices $269 $269 $1,064 $ Hemorrhoidectomy, internal, by rubber band ligation(s) $276 $198 $442 $ Sigmoidoscopy, flexible; with band ligation(s) (eg, hemorrhoids) $827 $ Colonoscopy, flexible; with band ligation(s) (eg, hemorrhoids) $790 $433 Injection Esophagoscopy, flexible, transoral; with directed submucosal injection(s), any substance Esophagoscopy, rigid, transoral; with directed submucosal injection(s), any substance Esophagoscopy, flexible, transoral; with injection sclerosis of esophageal varices Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance Esophagogastroduodenoscopy, flexible, transoral; with injection sclerosis of esophageal/gastric varices $283 $115 $1,064 $ $177 $177 $1,064 $ $151 $151 $745 $ $400 $154 $745 $ $259 $259 $745 $ Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance $280 $95 $494 $ Colonoscopy through stoma; with directed submucosal injection(s), any substance $790 $ Colonoscopy, flexible; with directed submucosal injection(s), any substance $473 $251 $790 $433 Inpatient Coding and Medicare Payment MS- DRG Description Inpatient Medicare National Average Payment GI Hemorrhage with Major Complication or Comorbidity (MCC 5 ) $10, GI Hemorrhage with Complication or Comorbidity (CC 5 ) $5, GI Hemorrhage without CC/MCC $3, Cirrhosis & alcoholic hepatitis with MCC 5 $9, Cirrhosis & alcoholic hepatitis with CC 5 $5, Cirrhosis & alcoholic hepatitis without CC/MCC $3,654 See important information about the uses and limitations of this document on pages 2 and 3 ENDO AF DEC2014 8

9 Polypectomy Procedural Reimbursement Guide - Select Endoscopy Procedures Code 1 Code Description Work Office Hot Biopsy Esophagoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps Snare Esophagoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by snare technique Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique Hot Biopsy or Snare Proctosigmoidoscopy, rigid; with removal of multiple tumors, polyps, or other lesions by hot biopsy forceps, bipolar cautery or snare technique Other Esophagoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) Foreign Body Removal In $430 $149 $1,914 $1, $469 $187 $1,064 $ $195 $195 $1,249 $ $448 $225 $790 $ $225 $93 $827 $ $302 $113 $494 $ $472 $277 $790 $ $459 $177 $1,064 $ $516 $215 $1,064 $ $224 $224 $1,249 $ $506 $263 $790 $ $226 $93 $827 $ $325 $144 $827 $ $532 $314 $790 $ $254 $116 $827 $ $747 $217 $1,914 $1, Esophagoscopy, flexible, transoral; with removal of foreign body(s) $419 $156 $1,064 $ Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body(s) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of foreign body(s) $419 $195 $745 $ $210 $210 $852 $ Proctosigmoidoscopy, rigid; with removal of foreign body $228 $106 $1,657 $ Sigmoidoscopy, flexible; with removal of foreign body(s) $297 $114 $827 $ Colonoscopy, flexible; with removal of foreign body(s) $510 $278 $790 $ Esophagoscopy, rigid, transoral; with removal of foreign body(s) $199 $199 $1,064 $584 Endoscopic Mucosal Resection Esophagoscopy, flexible, transoral; with endoscopic mucosal resection $260 $260 $1,064 $ Esophagogastroduodenoscopy, flexible, transoral; with endoscopic mucosal resection Colonoscopy through stoma; with endoscopic mucosal resection Sigmoidoscopy, flexible; with endoscopic mucosal resection Colonoscopy, flexible; with endoscopic mucosal resection $295 $295 $1,064 $584 RVUs Physician,2 3 $790 $433 $827 $454 $790 $433 Inpatient Coding and Medicare Payment Inpatient payment information not shown because the polypectomy procedure will rarely, if ever, be the primary reason for a hospital admission. See important information about the uses and limitations of this document on pages 2 and 3 ENDO AF DEC2014 9

10 Pulmonary Procedural Reimbursement Guide - Select Endoscopy Procedures Code 1 Code Description Work Office RVUs Physician,2 3 In- Biopsy Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial or endobronchial biopsy(s), single or multiple sites Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial lung biopsy(s), single lobe Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial lung biopsy(s), each additional lobe (List separately in addition to code for primary procedure)* Cytology and Brush Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed (separate procedure) Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with brushing or protected brushings Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial alveolar lavage Foreign Body Removal (Stent Removal) Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with removal of foreign body Needle Aspiration Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i) Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), each additional lobe (List separately in addition to code for primary procedure)* Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with therapeutic aspiration of tracheobronchial tree, initial (eg, drainage of lung abscess) Stenting Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of tracheal stent(s) (includes tracheal/bronchial dilation as required) Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of bronchial stent(s) (includes tracheal/bronchial dilation as required), initial bronchus Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; each additional major bronchus stented (List separately in addition to code for primary procedure)* Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with revision of tracheal or bronchial stent inserted at previous session (includes tracheal/bronchial dilation as required) Balloon Dilation Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with tracheal/bronchial dilation or closed reduction of fracture Bronchial Thermoplasty Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 1 lobe Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 2 or more lobes $339 $176 $1,055 $ $379 $196 $1,055 $ $73 $50 $0 $ $319 $150 $1,055 $ $337 $151 $1,055 $ $319 $153 $1,055 $ $356 $195 $1,055 $ $600 $211 $2,255 $1, $90 $65 $0 $ $330 $167 $1,055 $ $240 $240 $2,255 $1, $229 $229 $2,255 $1, $77 $77 $0 $ $262 $262 $2,255 $1, $207 $207 $2,255 $1, $215 $215 $2,255 N/A* $225 $225 $2,255 N/A* See important information about the uses and limitations of this document on pages 2 and 3 ENDO AF DEC

11 Pulmonary Procedural Reimbursement Guide - Select Endoscopy Procedures Inpatient Coding Possible ICD-9-CM Procedure Codes Code Description Endoscopic excision or destruction of lesion or tissue of bronchus Bronchoscopic bronchial thermoplasty, ablation of airway smooth muscle Other bronchoscopy Closed endoscopic biopsy of bronchus; bronchoscopy (fiber-optic) with brush biopsy of lung, brushing or washing for specimen collection, excision (bite) biopsy Closed endoscopic biopsy of lung; Fiber-optic bronchoscopy with fluoroscopic guidance with biopsy, transbronchial lung biopsy Replacement of laryngeal or tracheal stent Other operations on trachea Removal of intraluminal foreign body from trachea and bronchus without incision Bronchial dilation Inpatient Medicare Payment MS- DRG Description Inpatient Medicare National Average Payment Respiratory neoplasms with Major Complication or Comorbidity (MCC 5 ) $9, Respiratory neoplasms pancreas with Complication or Comorbidity (CC 5 ) $6, Respiratory neoplasms without CC/MCC $4, Pulmonary edema & respiratory failure $7, Simple pneumonia & pleurisy with MCC 5 $8, Simple pneumonia & pleurisy with CC 5 $5, Simple pneumonia & pleurisy without CC/MCC $4, Interstitial lung disease with MCC 5 $9, Interstitial lung disease with CC 5 $6, Interstitial lung disease without CC/MCC $4, Respiratory signs & symptoms $4, Other respiratory system diagnoses with MCC 5 $8, Other respiratory system diagnoses without CC/MCC $4, Major Chest Procedures with MCC 5,7 $29, Major Chest Procedures with CC 5 $15, Major Chest Procedures without CC/MCC $10,687 See important information about the uses and limitations of this document on pages 2 and 3 ENDO AF DEC

12 Stenting Procedural Reimbursement Guide - Select Endoscopy Procedures Code 1 G-Code Code Description Work Office Biliary Stenting Endoscopic retrograde cholangiopancreatography (ERCP); with placement of endoscopic stent into biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent Endoscopic retrograde cholangiopancreatography (ERCP); with removal of foreign body(s) or stent(s) from biliary/pancreatic duct(s) Endoscopic retrograde cholangiopancreatography (ERCP); with removal and exchange of stent(s), biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent exchanged Esophageal Stenting Esophagoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) Esophagogastroduodenoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) Colonic and Duodenal Stenting Esophagogastroduodenoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with transendoscopic stent placement (includes predilation) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with transendoscopic stent placement (includes predilation) Ileoscopy, through stoma; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) G6018 Ileoscopy,through stoma;with transendoscopic stent placement (includes predilation) Colonoscopy through stoma; with endoscopic stent placement (including pre- and post-dilation and guide wire passage, when performed) G6020 Colonoscopy through stoma;with transendoscopic stent placement (includes predilation) Proctosigmoidoscopy, rigid; with transendoscopic stent placement (includes predilation) Sigmoidoscopy, flexible; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) G6023 Sigmoidoscopy, flexible; with transenoscopic stent placement (includes predilation) Colonoscopy, flexible; with endoscopic stent placement (includes pre- and post-dilation and guide wire passage, when performed) G6025 Tracheobronchial Stenting Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic stent placement (includes predilation) Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of tracheal stent(s) (includes tracheal/bronchial dilation as required) Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of bronchial stent(s) (includes tracheal/bronchial dilation as required), initial bronchus Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; each additional major bronchus stented (List separately in addition to code for primary procedure) * In $501 $501 $3,174 $1, $408 $408 $1,952 $1, $521 $521 $3,174 $1, $207 $207 $3,174 $1, $247 $247 $3,174 $1, $247 $247 $3,174 $1, $291 $291 $3,174 $1, $445 $445 $3,174 $1, $162 $162 Physician Only $267 $267 Physician Only $852 $467 Physician Only $790 $433 Physician Only $127 $127 $3,174 $1, $172 $172 Physician Only RVUs Physician, $340 $340 Physician Only $827 $454 Physician Only $790 $433 Physician Only $240 $240 $2,255 $1, $229 $229 $2,255 $1, $77 $77 $0 $0 See important information about the uses and limitations of this document on pages 2 and 3 ENDO AF DEC

13 Stenting Procedural Reimbursement Guide (Continued) Select Endoscopy Procedures Code 1 Code Description Work Office Foreign Body Removal (Stent Removal) In Esophagoscopy, flexible, transoral; with removal of foreign body(s) $419 $156 $1,064 $ Esophagoscopy, rigid, transoral; with removal of foreign body(s) $199 $199 $1,064 $ Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body(s) Endoscopic retrograde cholangiopancreatography (ERCP); with removal of foreign body(s) or stent(s) from biliary/pancreatic duct(s) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of foreign body(s) RVUs Physician, $419 $195 $745 $ $408 $408 $1,952 $1, $210 $210 $852 $ Proctosigmoidoscopy, rigid; with removal of foreign body $228 $106 $1,657 $ Sigmoidoscopy, flexible; with removal of foreign body(s) $297 $114 $827 $ Colonoscopy, flexible; with removal of foreign body(s) $510 $278 $790 $433 Inpatient Coding Possible ICD-9-CM Procedure Codes Code Description Insertion of permanent tube into esophagus Endoscopic insertion of colonic stent(s) Endoscopic insertion of stent (tube) into bile duct Replacement of laryngeal or tracheal stent Bronchial dilation Removal of intraluminal foreign body from trachea and bronchus without incision Inpatient Medicare Payment MS- DRG Description Inpatient Medicare National Average Payment Digestive malignancy with Major Complication or Comorbidity (MCC 5 ) $11, Digestive malignancy with Complication or Comorbidity (CC 5 ) $7, Digestive malignancy without CC/MCC $5, GI obstruction with MCC 5 $9, GI obstruction with CC 5 $5, GI obstruction without CC/MCC $3, Other digestive system diagnoses with MCC 5 $9, Other digestive system diagnoses with CC 5 $5, Other digestive system diagnoses without CC/MCC $3, Malignancy of hepatobiliary system or pancreas with MCC 5 $10, Malignancy of hepatobiliary system or pancreas with CC 5 $6, Malignancy of hepatobiliary system or pancreas without CC/MCC $5, Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis with MCC 5 $11, Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis with CC 5 $5, Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis without CC/MCC $3, Disorders of the biliary tract with MCC 5 $9, Disorders of the biliary tract with CC 5 $6, Disorders of the biliary tract without CC/MCC $4,439 See important information about the uses and limitations of this document on pages 2 and 3 ENDO AF DEC

14 Cholangioscopy Procedural Reimbursement Guide Select Endoscopy Procedures RVUs Physician,2 3 Code 1 Code Description Work Office Cholangioscopy Endoscopic cannulation of papilla with direct visualization of pancreatic/common bile duct(s) (List separately in addition to code(s) for primary procedure* In $128 $128 $0 $0 CPT Code is an add-on code and must be reported with at least one of the following ERCP codes: Code 1 Code Description Work Office Diagnostic Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) Therapeutic Endoscopic retrograde cholangiopancreatography (ERCP); with biopsy, single or multiple Endoscopic retrograde cholangiopancreatography (ERCP); with sphincterotomy/papillotomy Endoscopic retrograde cholangiopancreatography (ERCP); with pressure measurement of sphincter of Oddi Endoscopic retrograde cholangiopancreatography (ERCP); with removal of calculi/debris from biliary/pancreatic duct(s) Endoscopic retrograde cholangiopancreatography (ERCP); with destruction of calculi, any method (eg, mechanical, electrohydraulic, lithotripsy) Endoscopic retrograde cholangiopancreatography (ERCP); with transendoscopic balloon dilation of biliary/pancreatic duct(s) or of ampulla (sphincteroplasty), including sphincterotomy, when performed, each duct Endoscopic retrograde cholangiopancreatography (ERCP); with ablation of tumor(s), polyp(s), or other lesion(s), including pre- and post-dilation and guide wire passage, when performed Stenting Endoscopic retrograde cholangiopancreatography (ERCP); with placement of endoscopic stent into biliary or pancreatic duct, including pre- and postdilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent Endoscopic retrograde cholangiopancreatography (ERCP); with removal of foreign body(s) or stent(s) from biliary/pancreatic duct(s) Endoscopic retrograde cholangiopancreatography (ERCP); with removal and exchange of stent(s), biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent exchanged RVUs Physician,2 In $351 $351 $1,952 $1, $368 $368 $1,952 $1, $388 $388 $1,952 $1, $389 $389 $1,952 $1, $395 $395 $1,952 $1, $469 $469 $1,952 $1, $410 $410 $1,952 $1, $469 $469 $1,952 $1, $501 $501 $3,174 $1, $408 $408 $1,952 $1, $521 $521 $3,174 $1,313 See important information about the uses and limitations of this document on pages 2 and 3 ENDO AF DEC

15 Cholangioscopy Procedural Reimbursement Guide Select Endoscopy Procedures Inpatient Coding Possible ICD-9-CM Procedure Codes Code Description Endoscopic retrograde cholangiopancreatography (ERCP) Endoscopic retrograde cholangiography (ERC) Other closed (endoscopic) biopsy of biliary duct or sphincter of Oddi Inpatient Medicare Payment MS- DRG Description Inpatient Medicare National Average Payment Malignancy of hepatobiliary system or pancreas with Major Complication or Comorbidity (MCC 5 ) $10, Malignancy of hepatobiliary system or pancreas with Complication or Comorbidity (CC 5 ) $6, Malignancy of hepatobiliary system or pancreas without CC/MCC $5, Disorders of the pancreas except malignancy with MCC 5 $9, Disorders of the pancreas except malignancy with CC 5 $5, Disorders of the pancreas except malignancy without CC/MCC $3, Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis with MCC 5 $11, Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis with CC 5 $5, Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis without CC/MCC $3, Disorders of the biliary tract with MCC 5 $9, Disorders of the biliary tract with CC 5 $6, Disorders of the biliary tract without CC/MCC $4,439 See important information about the uses and limitations of this document on pages 2 and 3 ENDO AF DEC

16 Transendoscopic Ultrasound-Guided Fine Needle Aspiration Procedural Reimbursement Guide - Select Endoscopy Procedures RVUs Physician,2 3 Code 1 Code Description Work Office In- Upper Gastrointestinal Procedures Esophagoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), (includes endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures) Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis) $492 $216 $1,064 $ $255 $255 $1,064 $ $288 $288 $1,064 $584 Lower Gastrointestinal Procedures Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) Colonoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures $242 $242 $827 $ $384 $384 $790 $ Colonoscopy through stoma; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures $790 $433 Inpatient Coding and Medicare Payment Inpatient payment information not shown because the transendoscopic ultrasound-guided fine needle aspiration procedure will rarely, if ever, be the primary reason for a hospital admission. See important information about the uses and limitations of this document on pages 2 and 3 ENDO AF DEC

17 Footnotes The 2015 National Average Medicare physician payment rates have been calculated using a 2015 conversion factor of $ which reflects changes for January 1, 2015 through March 31, Rates subject to change. N/A* Medicare has not developed a rate for the setting as the procedure is typically performed in the hospital setting. * Add-on codes are always listed in addition to the primary procedure code. ** WallFlex, Percuflex C-Flex and Flexima Biliary RX Stent Systems as well as WALLSTENT Biliary Endoprostheses are not FDA-cleared for use in the pancreatic ducts. 1 CPT Copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. 2 Center for Medicare and Medicaid Services. CMS Physician Fee Schedule - January 8, 2015 revised release, RVU15A file Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files-Items/RVU15A.html?DLPage=1&DLSort=0&DLSortDir=descending 3 Source: November 10, 2014 Federal Register CMS-1613-FC. 4 National average (wage index greater than one) DRG rates calculated using the national adjusted full update standardized labor, non-labor and capital amounts ($5,865.48). Source: August 22, 2014 Federal Register. 5 The patient s medical record must support the existence and treatment of the complication or comorbidity. 6 May include but is not limited to one of the following hemostasis techniques: injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator. 7 Likely to pertain to bronchial thermoplasty only. 8 Based on estimate that non-medicare payment for outpatient hospital services is 2.17 times Medicare payment. Source: High and Varying Prices for Privately Insured Patients Underscore Market Power by Chapin White, Amelia M. Bond and James D. Reschovsky. See important information about the uses and limitations of this document on pages 2 and 3 ENDO AF DEC

18 Payment Table 1. Final 2015 Payments for Endoscopy Services* APC Description 2015 Medicare National Average Payment Level I Upper GI Procedures $ Level II Upper GI Procedures $1, Level III Upper GI Procedures $1, Endoscopic Retrograde Cholangio-Pancreatography (ERCP) $1, GI Procedures with Stents $3, Level I Tube or Catheter Changes or Repositioning $ Thrombolysis and Other Device Revisions $ Level I Small Intestine Endoscopy $ Level II Small Intestine Endoscopy $1, Lower GI Endoscopy $ Level I Sigmoidoscopy and Anoscopy $ Level II Sigmoidoscopy and Anoscopy $ Level III Sigmoidoscopy and Anoscopy $1, Level I Anal/Rectal Procedures $ Level I Endoscopy Lower Airway $1, Level II Endoscopy Lower Airway $2,255 * Note: There is a separate facility and physician payment for outpatient hospital services. The values in this table refer to the outpatient hospital facility payment only. See important information about the uses and limitations of this document on pages 2 and 3 ENDO AF DEC

19 Endoscopy C-Code Summary C-Code C-Code Description Devices Impacted 1 C1726 C1769 C1874 Catheter, balloon dilation, non-vascular Guide wire Stent, coated/covered, with delivery system C1875 Stent, coated/covered without delivery system Dynamic (Y) Stent C1876 C2617 C2625 Stent, non-coated/non-covered, with delivery system Stent, non-coronary, temporary, without delivery system Stent, non-coronary, temporary, with delivery system CRE Single-Use Fixed Wire Esophageal Balloon Dilators CRE Single-Use Pulmonary Balloon Dilators CRE Single-Use Wireguided Esophageal/Pyloric/Biliary Balloon Dilators CRE Single-Use Wireguided Esophageal/Pyloric/Colonic/Biliary Balloon Dilators CRE Single-Use Wireguided Biliary Balloon Dilators Hurricane RX Single-Use Biliary Dilatation Balloon Catheters MaxForce Biliary Balloon Dilatation Catheters MaxForce TTS Single-Use Balloon Dilators Rigiflex II Single-Use Achalasia Balloon Dilators All BSC guide wires used in GI procedures: Dreamwire Guidewire, Hydra Jagwire Guidewire, Jagwire Guidewire, Pathfinder Guidewire Polyflex Single-Use Esophageal Stent System Polyflex Single-Use Self-Expanding Silicone Airway Stent System Ultraflex Single-Use Covered Esophageal NG Stent System Distal Release Ultraflex Single-Use Covered Esophageal NG Stent System Proximal Release Ultraflex Single-Use Covered Large Esophageal NG Stent System Distal Release Ultraflex Single-Use Covered Large Esophageal NG Stent System Proximal Release Ultraflex Single-Use Covered Tracheobronchial Stent System - Distal Release WallFlex Biliary RX Fully Covered Stent System WallFlex Biliary RX Partially Covered Stent System WallFlex Fully Covered Esophageal Stent WallFlex Partially Covered Esophageal Stent System WALLSTENT Endoscopic Biliary Endoprosthesis Stents Ultraflex Precision Single-Use Colonic Stent System Ultraflex Single-Use Uncovered Esophageal NG Stent System Distal Release Ultraflex Single-Use Uncovered Esophageal NG Stent System Proximal Release Ultraflex Single-Use Uncovered Tracheobronchial Stent System Distal Release Ultraflex Single-Use Uncovered Tracheobronchial Stent System Proximal Release WallFlex Single-Use Colonic Stent System WallFlex Single-Use Duodenal Stent System WallFlex Biliary RX Uncovered Stent System WALLSTENT RX Biliary Endoprosthesis Stent System WALLSTENT Endoscopic Biliary Endoprosthesis Stents WALLSTENT Single-Use Colonic and Duodenal Endoprosthesis with UniStep Plus Delivery System Advanix Biliary Stent Advanix Pancreatic Stent C-Flex Double Pigtail Biliary Stent Percuflex Duodenal Bend Biliary Stents Advanix Preloaded Biliary Stent Systems Advanix Pancreatic Stent Kits Flexima Biliary Stent Systems Percuflex Duodenal Bend Biliary Stent with Introducer Kit 1 RX Biliary Stents with RX Delivery System C1886 Catheter, extravascular tissue ablation, any modality (insertable) Alair Bronchial Thermoplasty Catheter 1 For devices packaged in kits, hospitals may bill for the components of the kits that individually qualify for C-Codes. Facilities should bill for the estimated proportion of the kit that the C-Code eligible device comprises. See important information about the uses and limitations of this document on pages 2 and 3 ENDO AF DEC