If your gastroenterologist performed an ablation to destroy a tumor or a polyp, you will need to look:
- At the extent to which your gastroenterologist visualized the upper GI tract using the endoscope.
- what other procedures your gastroenterologist performed in the same session.
- Watch out for edit bundles as this might lead to incomplete payment of claims.
If your clinician performed an ablation and did not extend the scope beyond the esophagus, then you need to report the procedure using 43229 (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]). If your gastroenterologist visualized the areas of the stomach and beyond the pyloric channel into the duodenum and/or the jejunum, then you need to report the procedure using the code 43270 (Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor[s], polyp[s], or other lesion[s] [includes pre- and post-dilation and guide wire passage, when performed]).
When your gastroenterologist performs esophagoscopic photodynamic therapy (PDT), you will have to report this procedure with either of the add-on codes, +96570 (Photodynamic therapy by endoscopic application of light to ablate abnormal tissue via activation of photosensitive drug[s]; first 30 minutes [List separately in addition to code for endoscopy or bronchoscopy procedures of lung and gastrointestinal tract]) or +96571 (…each additional 15 minutes) along with 43229.
Note that +96570 and +96571 are selected based on time spent on performing PDT. For 23-37 minutes of service, use 96570. For 38-52 minutes of service, use 96570 in conjunction with 96571.
If you look at the code descriptors to the ablation codes, 43229 and 43270, you will notice that it mentions the phrase “includes pre- and post-dilation and guide wire passage, when performed.” This informs you that if your clinician had to overcome any obstruction or stricture by use of guide wire or dilators, you cannot report these procedures separately with 43229 and 43270. For example: you will not report 43248 (Esophagogastroduodenoscopy…with insertion of guide wire followed by passage of dilator[s] over guide wire) separately.
- Multiple EGD therapeutics in the same session.
When your clinician performs such multiple procedures, multiple endoscopic payment rules will apply. If your clinician is performing other EGD procedures in the same session in which he performs an ablation, you will also need to pay attention to Correct Coding Initiative (CCI) edits.
- Some of the EGD procedures that run into edits with 43270 include:
43250 (Esophagogastroduodenoscopy…with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery)
43251 (…with removal of tumor[s], polyp[s], or other lesion[s] by snare technique)
43254 (…with endoscopic mucosal resection)
43255 (…with control of bleeding, any method)
However, you can unbundle the codes with the use of a suitable modifier such as 59 (Distinct procedural service). So, if for example, your clinician performs removal of a polyp by ablation and removal of another polyp by snare technique in a different location, you can report both 43251 and 43270. You will have to append modifier 59 to 43251.
Note: If your clinician performs an ablation of a tumor or polyp and during the procedure encounters ablation related bleeding and controls it with a plasma coagulator, then you cannot report 43255 for the bleeding control. You cannot do this as the bleeding control is part of the polyp removal procedure and so cannot be reported separately. But, if the polyp removal and the bleeding control were in two different sites, you can use the modifier to unbundle the codes and report them separately. Provide documentation supporting your claims when you do so.
Please feel free to ask for any further query.