Category: Gastroenterology

02 May 2017

Fecal microbiota transplant: Procedure and coding guidelines

Fecal Transplant - Procedure and coding guidelines1

Fecal transplantation is a procedure performed for patients suffering from recurrent infections by a type of bacteria called Clostridium difficile. The infection is spread through contact with surfaces contaminated by spores of the bacterium. The range of symptoms include diarrhea, pseudomembranous colitis, fever, nausea and abdominal pain.

In recent times, there has been an increased antibiotic resistance for C. difficile. Fecal bacteriotherapy or stool transplant is an emerging technique for treating patients suffering from such antibiotic resistance.

The procedure
Fecal microbiota transplant (FMT) involves transplantation of fecal microbiota collected from a healthy individual into the gut of patient. The donor’s stool sample is carefully screened and selected for transplant.

A close relative may prove to be suitable donor however, non relatives stool samples may also be effective.

Fresh stools are often used for preparation of an infusion. Once ready, the infusion is administered by means of enema using a colonoscope or through a nasogastric tube.

Indications for the therapy
• Clostridium difficile infection

Coding guidelines

For Medicare:
CPT code to be reported – G0455 – Preparation with instillation of fecal microbiota by any method, including assessment of donor specimen

(Medicare does not pay a separate fee for the installation of the microbiota by oro-nasogastric tube, enema, or by upper or lower endoscopy)

ICD-10 codes that can be reported:

Z20.9 – Contact with and (suspected) exposure to unspecified communicable disease

Z22.1 – Carrier of other intestinal infectious diseases

Z11.59 – Encounter for screening for other viral diseases

Z11.3 – Encounter for screening for infections with a predominantly sexual mode of transmission

Z11.2 – Encounter for screening for other bacterial diseases

Z11.0 – Encounter for screening for intestinal infectious diseases

Z11.8 – Encounter for screening for other infectious and parasitic diseases

Z11.9 – Encounter for screening for infectious and parasitic diseases, unspecified

For commercial payors:
44705 – Preparation of fecal microbiota for instillation, including assessment of donor specimen
44799 – Fecal instillation by oro-nasogastric tube or enema (This CPT code is used to indicate  instillation).

Do not report 44705 in conjunction with 74283 (Therapeutic enema, contrast or air, for reduction of intussusception or other intraluminal obstruction (e.g., meconium ileus)

Have a coding question? Let me know in the comments below.

The information is presented for educational use only. It is not meant to be used to diagnose or treat any medical condition. We have made all reasonable efforts to ensure the information provided in this guide is accurate at the time of inclusion, however, please resort to clinical documentation and your experience to make decisions while coding and billing for procedures.

By Sandeep Paranjape, NextServices

Our new book Private Equity in Gastroenterology – Navigating the Next Wave is still available for download. Here was the best compliment we got to date: “I need my entire board to read this!”
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07 Mar 2017

[FREE GUIDES] 2019 CPT CODES & ICD-10 CODING GUIDELINES FOR ENDOSCOPY PROCEDURES

1. [FREE GUIDE] CPT CODES FOR ENDOSCOPY PROCEDURES

Remembering codes with so many permutations and combinations can be really overwhelming. To help you understand and code better, we have created this reference guide which you can refer to code and bill accurately for your next case. Guide includes CPT Codes for Colonoscopy, Esophagoscopy, EGD, Enteroscopy, ERC and Sigmoidoscopy.

 

 

2. [FREE GUIDE] ICD-10 CODING GUIDELINES FOR SCREENING & SURVEILLANCE COLONOSCOPY

October 1st, 2016 marked the end of the grace period allotted by CMS and AMA to facilitate smooth ICD-10
implementation. During the grace period, insurances processed claims even if they were wrongly coded, just as
long as the codes belonged to the broader family of correct codes. However, such claims will not be paid after
the grace period. It now becomes crucial for medical practices to strictly adhere to ICD-10 coding guidelines to
avoid payment disruptions.

Guide includes ICD-10 Coding guidelines for screening and surveillance colonoscopy.

 

 

Disclaimer – The information is presented for educational use only. It is not meant to be used to diagnose or treat any medical condition. We have made all reasonable efforts to ensure the information provided in these guides are accurate at the time of inclusion, however, please resort to clinical documentation and your experience to make decisions while coding and billing for procedures.

Our new book Private Equity in Gastroenterology – Navigating the Next Wave is still available for download. Here was the best compliment we got to date: “I need my entire board to read this!”


downloadnow

18 Feb 2017

How to code for ulcers according to ICD-10 guidelines

With ICD-10, reporting for type, occurrence site, and complication has dramatically increased coding complexity. There are codes ranging from problems in relationship with in-laws (Z63.1) to being pecked by a chicken (W61.33) to being bitten by a sea lion (W56.11)!

Ulcer is one of the most frequently reported diagnosis codes in gastroenterology. However, with the advent of ICD-10, coding for the simple diagnosis has become complicated for even the most experienced doctors.

To make your life a little easier, we compiled a list of accurate coding guidelines for ulcers that you could refer to for your next case.

Ulcers are broadly classified based on the organ they are present.

1) Gastric ulcer (K25)

2) Duodenal ulcer (K26)

3) Peptic ulcer (K27)

4) Gastrojejunal ulcer (K28)

Each type of ulcer is further classified into acute or chronic. If the nature of ulcer cannot be determined, an “unspecified” code may be used.

Coding now goes up to the 4th level (or the fourth digit of ICD-10 code) of specificity. Each type of ulcer is coded with reference to the complications associated with it. For example, the code used for Acute gastric ulcer with hemorrhage would be K25.0

The ICD-10 CM manual also instructs the use additional codes if the patient is diagnosed with alcohol abuse and dependence.

F10 is the ICD-10 code for alcohol related disorders which is classified further into alcohol abuse (F10.1), alcohol dependence (F10.2), alcohol use, unspecified (F10.9). The F10 code can be further specified by the use additional codes. For example, blood alcohol level measurement is Y90.

Let’s understand this using a patient scenario:

Joan, age 36 years, presented with abdominal pain, nausea, vomiting and melena. She was scheduled for EGD after unsatisfactory PPI treatment. EGD revealed acute duodenal ulcer which was bleeding along with perforations. She consumes alcohol every day and shows withdrawal delirium. Her blood alcohol levels were 72 mg/100ml.

The coding for this scenario would be as follows:

Primary code: K26.2 (because the type of ulcer is duodenal and it is acute with hemorrhage and perforation)
Secondary code: F10.231 (because she exhibits alcohol dependence with withdrawal delirium)
Tertiary code: Y90.3 (because of the range of her blood alcohol level is 60-79 mg/100 ml)

This is how you think in an ICD-10 world. More specifically.

Below are coding guidelines in a tabulated format:

How to use this table:

The (*) mark specifies the nature of the condition.

For example, if an ulcer is duodenal, is acute and hemorrhage is present – the code to use would be K26.0

Another example, if an ulcer is peptic, is chronic/unspecified and hemorrhage is present – the code to use would be K26.4

Correct coding practices are the backbone for clean claims. Submitting clean claims with high first-pass ratio bring predictability in reimbursements. Pay attention to the levels of specificity that ICD-10 demands.

Have you come across any unique coding scenarios? Let me know in the comments below.

_

By Sandeep Paranjape, NextServices

Related:

[FREE GUIDE] How to bill accurate codes for endoscopy procedures

Adhere to ICD-10 coding guidelines now [avoid payment disruptions]

 

Our new book Private Equity in Gastroenterology – Navigating the Next Wave is still available for download. Here was the best compliment we got to date: “I need my entire board to read this!”
downloadnow
20 Dec 2016

Product and Feature Launches in 2016

Major enki features and products launched in 2016.

enki-endowriter

 

enki Telemedicine
enki Telemedicine module lets you seamlessly connect to your patients wherever they are. Enable remote healthcare delivery in a secure and simple way using video and messaging based consults.

 

 

enki Patient Portal

The new and improved version of enki Patient Portal allows patients a convenient access to their medical records 24×7. The patient portal also integrates enki Telemedicine modules for virtual consults. Patients can interact with you, request appointments and medication refills directly through secure messaging modules.

EndoWriter

enki EndoWriter helps you capture endoscopy images and document your procedures effortlessly. Cloud based technology frees you up from expensive hardware and provides access to your notes from anywhere. One platform integration with enki EHR greatly improves your efficiency.

 

enki-telemedicine

 

ICD-10 integration

enki EHR demonstrates complete ICD-10 integration across all clinical documentation modules. The simplified ICD-10 code selection interface guides you to the accurate diagnosis code for documenting your cases in a structured and compliant way.

 

 

 

 

21 Jul 2016

Adhere to ICD-10 Coding Guidelines Now [avoid payment disruptions]

October 1st, 2016 marks the end of the grace period allotted by CMS and AMA to facilitate smooth ICD-10 implementation. During the grace period, insurances processed claims even if they were wrongly coded, just as long as the codes belonged to the broader family of correct codes. However, such claims will not be paid after the grace period. It now becomes crucial for medical practices to strictly adhere to ICD-10 coding guidelines to avoid payment disruptions.

Here are a few guidelines for screening and surveillance colonoscopy.

Difference between screening and surveillance colonoscopies
Screening is a test provided to a patient in the absence of signs or symptoms. A screening colonoscopy is a service performed on an asymptomatic person for the purpose of testing the presence of colorectal cancer or colorectal polyps.
A surveillance colonoscopy can be performed at varying ages and intervals based on the patient’s personal history of colon cancer, polyps, and/or gastrointestinal disease. For example, patients with a history of colon polyps are not recommended for a screening colonoscopy, but for a surveillance colonoscopy.


Coding guidelines
ICD-10 guidelines clearly demarcate between coding for screening and surveillance.

Screening for malignant neoplasm of  ICD-10 code
Stomach Z12.0
Intestinal tract, unspecified Z12.10
Colon Z12.11
Rectum Z12.12
Small intestine Z12.13
Other sites Z12.89
Site unspecified Z12.9
Non cancerous disorders ICD-10 code
Screening for upper GI disorder Z13.810
Screening for lower GI disorder Z13.811
Screening for other digestive disorders Z13.818

 

Additional codes for family history of malignant neoplasm

Z80.0 –   Family history of malignant neoplasm of digestive organs

Z83.71 – Family history of colonic polyps

Z83.79 – Family history of other diseases of the digestive system

 

Surveillance colonoscopy codes

Z08 – Encounter for follow up examination after completed treatment of malignant neoplasm.
Use additional code for personal history of malignant neoplasm (Z85.-)

Organ Malignancy ICD-10 Code
Stomach Carcinoid tumor Z85.020
Other malignant neoplasm Z85.028
Large intestine Carcinoid tumor Z85.030
Other malignant neoplasm Z85.038
Rectum, rectosigmoid junction, anus Carcinoid tumor Z85.040
Other malignant neoplasm Z85.048
Liver Malignant neoplasm Z85.05
Small intestine Carcinoid tumor Z85.060
Other malignant neoplasm Z85.068
Pancreas Malignant neoplasm Z85.07
Other digestive organs Malignant neoplasm Z85.09

Z09 – Encounter for follow up examination after completed treatment for conditions other than malignant neoplasm.

[Read: Choosing between Modifier 53 and 52 – Gastroenterology example]

Additional codes to identify any applicable history of diseases (Z86.-, Z87.-)

Z86.010 – Personal history of colonic polyps
Z86.012 – Personal history of benign carcinoid tumor
Z86.018 – Personal history of other benign neoplasm
Z86.03 – Personal history of neoplasm of uncertain behavior
Z86.19 – Personal history of other infectious and parasitic diseases.
Z87.11 – Personal history of peptic ulcer disease
Z87.19 – Personal history of other diseases of digestive system

Colonoscopies account for majority of a gastroenterologist’s revenues. It’s important that doctors and their coders pay close attention to the specificity that ICD-10 demands. Systems like enki EHR help in directing doctors to code correctly at the point of care.

Related:

[FREE GUIDE] How to bill accurate codes for endoscopy procedures

How to code for ulcers according to ICD-10 guidelines

Our new book Private Equity in Gastroenterology – Navigating the Next Wave is still available for download. Here was the best compliment we got to date: “I need my entire board to read this!”
downloadnow
09 Apr 2016

Our latest updates on Becker’s ASC

blog_updatesonbeckersASC

1. NextServices Showcases Solutions at Digestive Disease Week 2014
(GI Endoscopy-Driven Surgery Centers to Know 2013) NextServices announces endoscope integration with enki EHR at DDW 2014.
2. How Do GI Coding Changes Affect the Field? Reimbursement, Technology, Denials & More 
(ASC Coding, Billing and Collections) Praveen Suthrum, president and co-founder of NextServices, explains what the 2014 changes mean for gastroenterologists and GI-driven ambulatory surgery centers.
3. How to Boost Clean Claims Submission at ASCs 
(ASC Coding, Billing and Collections)Nextservices blog post outlined on how ambulatory surgery centers can achieve 95 percent clean claims submission ratio.

4. Sending Patient Statements: Tips From NextServices 
(News & Analysis) In a recent blog, NextServices provided the most effective methods for sending patient statements in order to see results.
5. 11 Esophagoscopy Code Updates to Know 
(ASC Coding, Billing and Collections) Gastroenterology coding changes.
6. Collect From Patients: Best Practice for Sending Statements 
(News & Analysis)NextServices recently posted an article about sending patient statements on their blog. The article discusses whether providers should send patient statements daily or in bulk.
7. NextServices Exhibits EHR Through Google Glass 
(News & Analysis) NextServices announced it has unveiled the prototype for enki Glassware at FutureMed in San Diego.
8. Futuristic Healthcare: 7 Considerations for Ambulatory Surgery Centers 
(ASC Turnarounds: Ideas to Improve Performance) Praveen Suthrum, president and co-founder of NextServices provides a look ahead for ambulatory surgery centers.

09 Apr 2016

What does it mean that 25% of ALL coding changes are related to Gastroenterology?

blog_codingchangesarerelatedtogastroenterology

American Medical Association (AMA) added 175 new codes, revised 107 CPT/ procedure codes this year – 25% of them are related to gastroenterology (26 new codes, 41 revised codes and 17 deleted codes). Let’s consider an example.

If a patient showed up with a tumor in her esophagus, a gastroenterologist typically performs an esophagoscopy using snare technique to remove the tumor. A new technique has been doing the rounds during the past few years called Endoscopic Mucosal Resection (EMR) – it uses a suction mechanism to yank the tumor out from the skin before it’s cut. The technique helps in controlling unnecessary bleeding. Up until this year, EMR had no code. But this year, AMA recognized it with  43211 – a new code.

Up until this year, it didn’t matter whether a gastroenterologist used a flexible/ rigid scope or went in through the nose/ mouth during an esophagoscopy. But with the coding changes, it matters now – there’s increasing specificity.

What do examples of such coding additions/ changes mean for gastroenterology? At a very broad level, it simply means that there’s a shift underway. The patients are the same, the disease conditions are similar but how something can be diagnosed and treated is actively undergoing a change. Ambulatory surgery centers consider traditional upper and lower GI procedures as their bread and butter. But with steady innovation, better understanding and wider spread of newer techniques, the specialty will become even more specialized. Traditional procedures will continue to see declining reimbursements.

Knowing what we know of medicine, as procedures become mainstream, reimbursements decline and newer techniques become the preferred approach. It may be entirely possible that EMR may replace traditional esophagoscopy in the future. What if enough artificial intelligence algorithms may be built in to identify polyps from a video produced by a Video Capsule Endoscopy? What if the algorithms identify all possible polyps big and small throughout the digestive tract? Such thorough and extreme accuracy would be impossible with traditional colonoscopy that involves human hands and eyes. What would happen then to doctors who are not used to learning or experimenting with new procedures?

It’s also expected that in 2015, there would be lower gastroenterology coding changes. These coding changes are simply an acceptance of newer methods to treat and fix conditions and also a gentle nudge to gastroenterologists to stay current in their fields.

By Praveen Suthrum, President & Co-Founder, NextServices

09 Apr 2016

Esophagoscopy coding changes in 2014

blog_esophagoscopycodingchanges

Upper gastroenterology coding has seen important changes since Jan 1, 2014 – particularly, esophogoscopy procedures. Separate codes have been introduced for rigid esophagoscopy and flexible esophagoscopy.

Six new procedure codes have made an entry for rigid esophagoscopy this year. However, these codes are to be used only when esophagoscopy is done via the transoral route. In 2013, there were no separate codes for rigid transoral esophagoscopy – rigid or flexible esophagoscopy were included under the same definitions. In 2014, the specificity has increased based on the route of administration of scope i.e., transoral or transnasal and on whether the scope used was flexible or rigid.

If a rigid scope was used, the following new codes may be applied for the transoral route:

43191 – Rigid transoral e1sophagoscopy, diagnostic, brushing and washing. By using rigid scopes, procedures such as submucosal injections, biopsy, foreign body removal, balloon dilation, guide wire insertion and dilation over guide wire can be performed. CPT codes from 43192 through 43196 have been created to be used for these procedures.

If a flexible scope is used, but the route of administration is transnasal, these codes may be used:

43197 – Flexible transnasal esophagoscopy, diagnostic, brushing washing.

43198 – Flexible transnasal esophagoscopy, with biopsy.

Certain terminologies with respect to esophagoscopy have been revised. For e.g. CPT code 43200 is defined as ‘flexible’ (in 2014) as against ‘rigid or flexible’ (in 2013). CPT codes from 43200 through 43232 are now termed as flexible. The other specifications of the code descriptor remain the same.

New codes for Flexible Transoral Esophagoscopy

43211 – Flexible transoral esophagoscopy, mucosal resection. Till 2014, esophageal mucosal resection was reported by using unlisted codes 43499 (unlisted procedure, esophagus).

43212 – Flexible transoral esophagoscopy, stent placement, dilation and guide wire passage.

A new concept has been introduced, flexible transoral esophagoscopy with retrograde dilation with CPT code 43213.

43214 – Flexible transoral esophagoscopy, balloon dilation, including imaging. The imaging has been included effective 2014. Till 2014, imaging if performed had to be separately reported.

43229 – Flexible transoral esophagoscopy, with ablation, dilation and guide wire passage. This code now includes balloon dilation (43220), insertion of guide wire (43226) and ablation (43228).

By Sandeep Paranjape, Clinical and Coding expert, NextServices

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