A Lot to Swallow With 2015 Gastroenterology CPT® Changes

2015 Gastroenterology CPT® Changes

Finally, we reach the end of our coverage of the AMA’s 2016 CPT® and RBRVS Symposium! We finish up today with a review of changes to gastroenterology coding.

Get With the Gastroenterology Changes to CPT®

Glenn D. Littenberg, MD, FASGE, MACP, a member of the CPT® advisory committee who represents the American Society of Gastrointestinal Endoscopy, presented the changes to gastroenterology codes. First up is 43210, a new code for esophagogastric fundoplasty, which may be called a transoral incisionless fundoplication (TIF) procedure on the operative report. “In this antireflux procedure, as with other fundoplications, we are trying to create a competent lower esophageal sphincter, cinching it up with the top part of the stomach,” said Dr. Littenberg, performing the procedure with an endoscope. New code 43210 differs from existing codes 43279-43281, 43327, and 43328 in that the 43210 is performed transorally with endoscopy, while the existing codes are performed via laparoscopy, thoracotomy, or laparotomy. The TIF procedure is only appropriate for small hiatal hernias, and it includes duodenoscopy when performed.

Review New Category III Codes for Esophageal Sphincter Augmentation

CPT® adds codes 0392T (Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (i.e., magnetic band]) and 0393T (Removal of esophageal sphincter augmentation device) for laparoscopic creation of an artificial sphincter at the lower esophageal sphincter. In this procedure, also called a LINX procedure because only one company currently makes the device, providers place a ring of magnetic beads around the incompetent esophagogastric junction. “This seems to be a durable device,” said Dr. Littenberg, “with good five-year outcomes in a limited population.” The advantage of this device is that the bead chain expands when the patient swallows a bolus of food, as a normal lower esophageal sphincter would. The magnetic bead chain also allows the patient to belch, which standard fundoplication procedures do not. “It’s always nice to be able to belch,” Dr. Littenberg said.

Changes in Codes for Esophageal Balloon Distention Provocation

The definition of 91040, in which a provider dilates a patient’s esophagus with a balloon, saw revision to include language indicating that it is used as a diagnostic study, with provocation. The older use of this test included passage of a balloon into the esophagus with distention. The pressure might reproduce some chest pain symptoms, which would help diagnose unexplained chest pain differing from standard reflux pain, proving it was esophageal in nature and not caused by cardiac pathology. This use of the procedure has largely been supplanted with newer technology. However, the old balloon distention study has found new uses in evaluation of the effectiveness of surgery to correct achalasia, or the failure of the lower esophageal sphincter to open. When providers use a procedure like peroral esophageal myotomy (POEM) to repair achalasia, an esophageal balloon distention study done real time during the POEM procedure can help ensure adequate repair of the achalasia prior to ending the procedure.

ERCP With Optical Endomicroscopy (OE) Gains Category III Status

Be sure to catch that CPT® 2016 adds 0397T, a new category III code for endoscopic retrograde cholangiopancreatography (ERCP) with optical endomicroscopy (OE). OE procedures give a histology-like microscopic view of the tissue right with the endoscope, which is something you can’t get with standard or high definition endoscope, said Dr. Littenberg. This procedure is good for evaluating patients with Barrett’s esophagus and esophageal dysplasia that might lead to cancer. While the new code 0397T allows reporting of OE during ERCP, optical endomicroscopy performed with esophagogastroduodenoscopy already had category I codes, including 43206 (Esophagoscopy, flexible, transoral; with optical endomicroscopy) for OE limited to the esophagus and 43252 (Esophagogastroduodenoscopy, flexible, transoral; with optical endomicroscopy).

New category III code 0397T applies the OE technology to the ERCP arena at the bile duct and duct regions, where it’s especially useful because it can be difficult to distinguish benign from malignant pancreatic duct lesions. Report 0397T in conjunction with an appropriate existing ERCP code such as 43260-43265 or 43274-43278. Do not report 0397T in conjunction with 88375, and do not report OE more than once per session, even if the physician looks at several ducts or ductal systems in that session.

Code Changes Allow Better Evaluation of Liver Elasticity

E/M with 91200: Existing code 91200 (Liver elastography, mechanically induced shear wave [e.g., vibration], without imaging, with interpretation and report) saw some back and forth discussion about whether an E/M code could be reported same day as 91200. Discussions between the AMA Specialty Society Relative Value Scale Update Committee (RUC) and CPT® Editorial Panel centered on the need to allow reporting E/M because 91200 often occurs on the same day that an E/M service would be performed. Eventually the CPT® Editorial Panel agreed that an E/M service can be reported on the same day as an E/M service.

Liver elastography procedures are used to evaluate stiffness of the liver, specifically whether a liver has fibrosis, fatty changes, or is normal. “This is good technology that uses ultrasound images in a unique way,” said Dr. Littenberg, to quantitate the degree of fibrosis, since stiff tissue bounces off sound waves more than mushy tissue does. Providers often use this procedure to differentiate among hepatitis C, hepatic steatosis, and other liver inflammatory disease to comply with payer requirements to stage the degree of liver fibrosis before authorizing hepatitis C treatment. This staging used to require liver biopsy but now the elastography procedure allows a biopsy-free staging process.

Now, Reimbursement for Management of Experimental Liver Assist Systems

CPT® 2016 adds a new category III code for the oversight of liver assist systems, Dr. Littenberg said. The new code, 0405T, allows reimbursement for management of an experimental liver assist device, which helps to keep patients alive while waiting for a liver transplant, similar to the way nephrologists once used kidney dialysis to support patients in acute renal failure until the kidneys could recover. Providers can use liver assist devices in cases of liver failure, such as when a patient has had a massive Tylenol overdose and would die without a new liver. The technology is still in clinical trials, but because it takes considerable physician work to manage the device, CPT® 2016 added the new category III code. “This work is separate from the work of caring for the patient — it’s actually for caring for the device,” Dr. Littenberg explained.

Review Lower Endoscopy Coding Changes for 2016

Finally, Dr. Littenberg discussed the results of the review of lower endoscopy codes for CPT® 2015. CMS delayed publishing these codes in 2015, instead creating G codes to mirror the old 2014 codes during the transition. In 2016, CPT® will delete these G codes and put new and revised CPT® codes into effect.

Don’t Miss Our Full Coverage of the 2016 Symposium!

We’ve been recapping the AMA’s 2016 CPT® and RBRVS Annual Symposium for four days now! Did you miss our coverage of day one? Check it out — it centered on the philosophy of the changes, adjustments to the relative value scale, and changes by CMS to physician payment. And our coverage of day two of the symposium focused on interventional radiology, molecular pathology, and pain management. Day three’s coverage ran in the blog yesterday, zeroing in on radiation therapy and cardiology coding changes. And stay tuned because we’re planning a webinar in mid-December to cover these changes more completely, plus two quick presentations at CodingCon in Orlando, December 2 to 4.

Are You a Current SuperCoder Subscriber?

Did you know that SuperCoder subscribers can get a sneak peek at CPT® 2016 code changes right now, including analysis and advice from the SuperCoder team? And if you aren’t already a subscriber, you’re missing out! Physician Coder is an economical and essential coding tool that coders shouldn’t be without. Check it out here!

About 

Susan taught health information and healthcare documentation at the community college level for more than 20 years. She has a special love for medical language and terminology. She is passionate about ensuring accurate patient healthcare documentation through education. She has a master's degree in healthcare administration, is a certified healthcare documentation specialist, and serves as immediate past president for the Association for Healthcare Documentation Integrity (AHDI).

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