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CMS Claims Processed Manual Chapter 12 - EUS

Samantha Posted Wed 03rd of April, 2019 17:41:38 PM
I code for a physician (MAC Part B) GI practice in Oregon (Noridian Juristiction F) Here is my question: In chapter 12 of the CMS Claims Processing Manual I noted this guidance under reporting of codes in the EUS series: “Therefore, when a diagnostic examination of the upper gastrointestinal tract ‘including esophagus, stomach and either the duodenum or jejunum as appropriate,’ includes the use of ultrasonography, the service is reported by a single code, namely 43259. Interpretation, whether by a radiologist or endoscopist, is reported under CPT code 76975-26. These codes may both be reported on the same day.” - (section 30.1) Beginning my investigation, our physicians confirm that no competition exists with radiology. Our radiology group also confirms that they neither attend EUS encounters, nor assist in the interpretation of the images or of the pathology if fna/bx performed. So it is clear that our endoscopists provide this service, what is not clear is whether we are actually able to bill for their interpretation due to contradictory guidance. Evidence FOR: 1. CMS states to report on the same day in their manual (this appears to be last reviewed in July of 2018) 2. CPT EUS codes do not include "radiologic supervision and interpretation" as other codes do. So it is not bundled per CPT description. I have read guidance that suggests the statement “with endoscopic ultrasound examination” bundles these codes but this is not how CPT suggests radiologic bundling for any other codes. It is always stated as “radiologic supervision and interpretation” and sometimes “when performed”. 3. Other GI practices in our Noridian Jurisdiction appear to be able to get these codes paid with Medicare and Medicare replacement plans as well as some other specific payers and now bill based on the payer’s determination. They appeal and discuss as applicable. 4. CCI edits appear to disallow it, per my online search. However per my phone conversation with CMS this pairing is NOT disallowed. CMS considers it payable as the CMS Claims Processing Manual trumps all other guidance including CPT as CPT is considered a guide to bill for multiple insurances. 5. The Compliance Tool on SuperCoder says all applicable EUS codes (43232, 43237, 43259, 45341, 45391) are not considered column 2 code 6. Additionally, guidance provided on SuperCoder causes me to question if we should consider billing more than just 76975. But we should also consider billing 76942 with FNA procedures as this is not disallowed by CCI edits or CPT. We are also considering billing Doppler studies with either 93979 or 93976 and celiac nerve blocks with 64680. Please note that if we were to report these, our documentation would meet all requirements including but not limited to: statement that the ultra-sonographic views and imaging were personally performed and interpreted by them, permanent recorded images of the regions or localized sites, description of the localization process, and a report of the procedure for which the guidance is utilized including findings and all other inclusions typically required during an operative session (e.g. type of sedation, consent, findings/ recommendations, etc.)
SuperCoder Answered Thu 04th of April, 2019 04:23:51 AM

Hi Samantha,


CPT data is provided by AMA (American Medical Association) and the guidelines specific to CPT codes are also defined by AMA. As per AMA guidelines for 2019, CPT code 76975 should not be billed with 43259. We should give preference to AMA guidelines when it comes to CPT codes.   


NCCI edits for Q2, 2019 (April – June) provided by CMS also suggests not to bill CPT code 76975 along with CPT code 43259. This code combination should not be billed. Even appending modifier 59 would not by pass the bundling edits since both codes cannot be billed in any circumstance.


If GI practices in Noridian Jurisdiction are getting these codes paid with Medicare and Medicare replacement plans as well as some other specific payers, then you should bill on the basis of payer’s determination in your locality, but as per coding guidelines provided by AMA, this combination cannot be billed.


In respect to reporting additional codes with FNA procedures/doppler studies and celiac nerve blocks, your documentation should strongly support the medical necessity for the additional procedure. Your payer will decide based on the submitted records. If your records are strong and the medical necessity can be justified, CPT codes to above mentioned procedures can be billed.



Samantha Posted Thu 04th of April, 2019 15:03:15 PM
Thank you for your time and thought on this multifaceted question. I do have a 2 follow up questions to specify. 1) As you stated, AMA guidelines should be preferred when using CPT (as CPT guidelines originate from AMA) but can you answer from a compliance standpoint if the CMS Claims Processing Manual (IOM) takes precedence over or is more authoritative than AMA/CPT? It sounds like you believe based on other GI practices receiving reimbursement that this should not be considered a compliance issue or "unbundling" if documentation supports...? 2) We would not be appending a 59 modifier. We would be appending a 26 modifier for physician skill in these instances. What confuses me is that most CCI edit information I see online does not allow them, but Medicare on the phone says it has no CCI edit against the code pairing example 43259, 76975 - 26 modifier. So Medicare contradicts this guidance with the 26 modifier(making it payable). Do you believe that the edit suggests no payment would be received billing it with any modifier? And would you agree that the edits don't speak to compliance, but instead that they only speak to whether or not something is payable? Thank you very much for your time!
SuperCoder Answered Fri 05th of April, 2019 08:09:47 AM

Hi Samantha,


Yes. I agree to what you are saying. Since payers are getting this code combination paid, it would be safe to say that CMS is taking precedence over AMA in this specific case. Having said that, it may vary from case to case or scenario to scenario. There are some grey areas in medical coding field where things get stuck at times.  


If appending modifier 26 with CPT code for professional services is getting this code paid, you should bill it, but we would stick to the guidelines provided by AMA and NCCI which clearly suggest that this code combination cannot be billed in any circumstance. Appending modifier 26 or 59 would not bypass the CCI edits.


Per guidelines you should bill CPT code 43259 ONLY. That would be the correct way of billing and would ensure no compliance issues. If you are billing CPT code 76975 as well, you may get paid (since payers in your locality/state are getting paid) but there would always be a risk of audit which might consider it as a fraud act.


Kindly bill judiciously.



Samantha Posted Wed 10th of April, 2019 16:23:52 PM
Hello, I have followed up further on this information as I believe your working definition of fraud is faulty and can scare coders out of billing what is actually due to their practice. I spoke with Chelsea from CMS Noridian Medicare a couple of weeks ago. She returned my call today, same call reference for both calls: #468875. After reviewing with higher up claim auditors with CMS, she reiterates that these codes (43259 and 76975-26) are billable together on the same day by the same physician, payable and no CCI edit disallows. She states that not all CCI edit information is available to the public and that CCI edits only speak to what is payable, not compliance or fraud. She also shares that the Expert CPT on pages 784 and 1001 has no parenthetical note to disallow billing these codes. So per CPT Expert they are billable, which agrees with the IOM and allows their payment on the same date by the same physician. The CMS reps are still unclear why the CPT Professional addition would disallow them as the code description does not bundle these services, but says that the CPT Expert provides more detailed information from CMS. If we were to receive an audit, they could not consider it an act of fraud or abuse. The service was provided, documented, billed as described, in accordance with the IOM/CMS guidelines, and defensible by AMA code description with the work described not being included in reimbursement of the other code. We would not receive anything more than we are due. I almost fell into the same trap, but in order for this to be fraud, we would have to be receiving something other than what we are due and go directly against CMS guidelines. Simply put, AMA does not enforce healthcare law, and never will. They only communicate for CMS what the correct way to bill certain services are for most insurance companies. Per CPT Expert guidance, AMA contradicts itself and CMS. Please let me know if you have any additional thoughts. Thank you for your review of this information.
SuperCoder Answered Fri 12th of April, 2019 04:28:50 AM

Hi Samantha,


Thank you for sharing the information. Our judgement is mainly based on AMA, CMS, CCI edits and other information available on the websites. Scenarios like these do get stuck at times where one governing body contradicts the other body. I thank you for being gentle enough to provide further information (as shared with you by rep from CMS) on the billed scenario.


Much appreciated. 



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