CPT 30075, 30473, 30688 - Panendoscopy

 CPT CODE and Description


30075-16 [977] Biopsy of pancreas

30473-00 [1005] Panendoscopy to duodenum

30688-00 [1949] Endoscopic ultrasound




DOUBLE BALLOON ENTEROSCOPY


Double balloon enteroscopy (DBE) is an endoscopic technique that allows examination of the small intestine beyond the reach of other endoscopes.


** Revision of ACHI Index pathways to eliminate inconsistencies for double balloon enteroscopy (DBE) when performed via retrograde (per rectal) approach.

** Inclusion terms for balloon procedures at Index pathways for panendoscopy blocks [1005] – [1008] have been removed

** Creation of new code 30680-00 Balloon enteroscopy at block [1005] Panendoscopy,

** Assign 30680-00 [1005] Balloon enteroscopy in conjunction with interventions classified to blocks [892], [957], [1006], [1007] and [1008] when performed with double balloon enteroscopy.


30473-00 [1005] Panendoscopy to duodenum


As per WA Coding Rule 0316/09 Double balloon enteroscopy, effective 30 Mar 2016 - 30 Jun 2019, no look up exists at ‘Jejunoscopy’, so the lead term ‘Enteroscopy’ must be used, leading to the assignment of a panendoscopy code.


INSTRUCTION FOR PANENDOSCOPY


General Instructions:


1. If you are Diabetic, please contact the physician that manages your diabetes. They will give you instructions for adjusting your medications for the prep. Let your

physician know you will not be eating/drinking anything after midnight.


2. Take all medications for your heart or blood pressure the morning of the test, with a sip of water. Do NOT take any diuretics (water pills). Examples: Furosemide

(Lasix), Hydrochlorothiazide (HCTZ), Diuril, Aldactone…..


3. If you take blood thinners (Aspirin, Coumadin, Plavix, etc. ), please be sure we are aware of this. We will contact your prescribing doctor for specific instructions.


4. Due to sedation used during the exam, you will not be able to drive or return to work the day of your procedure.


Remember:


1. Eight (8) hours prior to your arrival time: NO solid foods.

 NO milk or milk products. NO red dyes. NO alcoholic beverages or beer. You  can continue the clear liquids for four (4) more hours.


2. Four (4) hours before your arrival time: Stop all clear liquids.


3. Take your medications with a sip of water, at least two hours before your arrival  time.


4. Bring with you: current medication list, photo ID, insurance cards, and the  blue questionnaire.



Clear liquids are allowed up to 4 hours before your arrival time:


Water, clear fruit juices (apple, white grape, white cranberry), bouillon, Jell-O (NO red Jell -O or fruit added), Ginger ale, Fresca, Coke/Pepsi, Gatorade (NO reds), Kool-Aid, SevenUp, Popsicles, or tea (no milk).


Before your Procedure


There are a few things that we ask all patients to do prior to coming in for their endoscopic procedure:


* Please follow all instructions given to you by your physician about eating, drinking and medications before your procedure. FOLLOW OUR INSTRUCTIONS, NOT WHAT COMES IN THE PREP BOX.

* If you are taking any medications, or if you are allergic to any medications, please bring a list of them with you when you come for your procedure.

* If you take any blood thinners and have not been instructed regarding usage prior to your procedure, please contact your physician as soon as possible.

* Notify your physician if there have been any changes in your physical condition since your last appointment was scheduled or since you last saw your physician.

* Please do not arrive prior to 6:45 am


Appointments:


Please be considerate of other patients and your physician by calling our office as soon as possible if you cannot keep your appointment. We understand that circumstances beyond your control may arise, exceptions will be made in the event of inclement weather or real emergencies Every health plan is different. While we make every effort to obtain referrals from primary care physicians and authorizations for outpatient procedures, it is also important for you to be familiar with your health care coverage.


We cannot be held responsible for unpaid services due to lack of referral or prior authorization.



A panendoscopy is the examination of the upper aerodigestive tract (pharynx, larynx, upper trachea and oesophagus). It may also involve the removal or biopsy of any abnormal tissue found.


Patient Information Panendoscopy and Biopsy


What is a panendoscopy and biopsy?


This operation is usually performed when there is suspicion of a cancer within the head and neck. It allows the surgeon to fully assess the oral cavity, larynx (voicebox) and oesophagus (food-pipe) to identify the extent of any growths, and take biopsies (which can include a tonsillectomy) to aid in diagnosis.


What is the operation like?

This is usually a day stay procedure. Before the operation you will see a member of the surgical team and the anaesthetist. The operation is performed with you asleep under a general anaesthetic for approximately 20 minutes.


You will wake up in the recovery room and once the anaesthetic has worn off you will be seen by your surgeon to explain the findings. If there are no significant problems you will then be discharged home with painkillers and an appointment to come back for any biopsy results. You will have a sore throat (especially if tonsillectomy was performed), and this will gradually improve over a week or two.


What can go wrong ?

The surgery is usually safe and uncomplicated however it is important that you are aware of the risks of the procedure.

General complications such as nausea, vomiting, sore throat and drowsiness may occur as a result of the anaesthetic. Serious drug reactions related to the anaesthetic are very rare.


Laparoscopic/arthroscopic/endoscopic surgery.


What is the correct code to assign for a nasendoscopy with views to the larynx** Should the instruction in ACS 0024 Panendoscopy to code to the furthest site viewed be applied to assign a code for laryngoscopy?


Panendoscopy is a generic term for an endoscopy of the upper gastrointestinal tract (ie oesophagus, stomach and duodenum) or aerodigestive tract (ie pharynx, larynx, upper oesophagus). ACS 0024



Panendoscopy states:

The term panendoscopy can also be used to mean endoscopies of the respiratory tract and the urinary system and therefore nongastrointestinal endoscopies should be coded appropriately, to the furthest site viewed


This advice only applies where the term panendoscopy is documented. Where specific types of endoscopes (nasendoscopy, laryngoscopy) are documented these should be coded as such. For example, if documentation indicates a nasendoscopy with views to the larynx has been performed, assign 41764-00 [370] Nasendoscopy. A separate code from block [520] Examination procedures on larynx should be assigned if documentation indicates a laryngoscopy has also been performed.


What is the correct procedure code for biopsy of a lesion using EUS guidance?


Endoscopic ultrasound (EUS) is similar to other endoscopies but with an ultrasound probe attached at the end of the endoscope, which permits both visualisation and tissue sampling of gastrointestinal walls and structures surrounding the gastrointestinal tract. EUS is primarily used for assessing lesions in the gastrointestinal tract, but has increasingly been used for evaluating lesions of adjacent organs such as lung, mediastinum, left kidney, adrenal gland and lymph nodes (intra-thoracic and intra-abdominal).


When biopsy of a lesion is performed under EUS guidance, assign an appropriate code for the type of endoscopy (e.g. gastroscopy, gastroscopy with biopsy) and 30688-00 [1949] Endoscopic ultrasound. For example, EUS guided FNA (fine needle aspiration) biopsy of pancreas, assign:


30075-16 [977] Biopsy of pancreas

30473-00 [1005] Panendoscopy to duodenum

30688-00 [1949] Endoscopic ultrasound



Coding and Billing


At this time, TNE uses the same coding procedures as conventional endoscopy. Diagnostic TNE (43200) and TNE with biopsy(s) (43202).


TNE Versus Conventional Esophagoscopy


Since the introduction of TNE, there have been many studies comparing TNE with the ‘‘gold standard’’ of conventional esophagoscopy (CE), which is performed transorally with sedation. Studies utilizing small-caliber video endoscopes have almost all concluded that TNE image quality and diagnostic capability is equivalent to CE, and that the majority of patients prefer TNE to CE.94–102


A summary review of these and other comparative studies was recently published as a portion of the American Academy of Otolaryngology position paper on TNE.82


TNE is also less expensive than CE. The increased direct costs of CE include longer procedure time, recovery room and recovery time, and the costs associated with medications, monitoring, and nursing.103 The difference in cost has been found to be greater than $2,000 per procedure.104 Indirect costs are also important but

difficult to quantify. This includes loss of work time by both the patient and a driver or caretaker. In contrast, with TNE, most patients are able to return to work or home shortly after the completion of the examination and do not need a caretaker.


Studies have shown a very high patient satisfaction rate, often greater than with CE.81,93 Crossover studies have shown that in patients who had both sedated and

unsedated examinations, the unsedated transnasal endoscopy was better tolerated.97


The Future


We anticipate that the future will bring continued refinements, such as still smaller endoscopes and the development of novel instruments to be used in conjunction with them. In addition, new techniques in imaging have emerged showing promise for enhancement and better visualization of the microvascular patterns of mucosal surfaces. Of particular interest is NBI optical technology, as noted earlier.105,106 NBI employs the filtering of light into three narrow bandwidths. This allows for optimal visualization of surface capillary and mucosa patterns, which the literature has suggested may allow for better evaluation and diagnosis of esophageal lesions. This may very well lead to improvement in the diagnosis of Barrett’s metaplasia, adenocarcinoma, and head and neck squamous cell cancer.


Conclusion


In-office TNE has become an important part of the evaluation and management of patients with dysphagia, extraesophageal/gastroesophageal reflux disease, and head and neck cancer. TNE provides a number of advantages over conventional endoscopy with equivalent clinical results. These advantages are improved safety, decreased overall costs, and patient preference.


MISCELLANEOUS LARYNGEAL PROCEDURES IN THE OFFICE SETTING


Laryngeal Biopsy


The revival of interest in awake laryngeal techniques has led to the development of additional procedures that offer novel value in care of the laryngology patient.

Perhaps the largest and most widely applicable is awake laryngopharyngeal biopsy. Although its roots are over 100 years old, awake laryngeal biopsy has seen a resurgence with the development of new endoscopes, endoscope sheaths, and instrumentation. Until approximately 15 years ago, the primary means for awake

laryngopharyngeal biopsy was similar to the approach used by the fathers of laryngology in the mid 1850s: transoral passage of long curved biopsy forceps with

indirect mirror laryngoscopy guidance. Although visualization is now achieved with rigid or flexible endoscopes with video display of the image rather than laryngeal

mirrors, the technique remains largely unchanged. However, in addition to the peroral biopsy approach, laryngeal biopsy can be done via the working channel of a flexible endoscope.


After adequate laryngopharyngeal anesthesia (as described previously), the patient is positioned sitting upright in the sniffing position. When using a rigid endoscope transorally, the patient holds their tongue protruded. The otolaryngologist holds the rigid endoscope in one hand and the biopsy forceps in the other.

The patient is asked to breathe comfortably through their mouth as the forceps are introduced into the laryngeal introitus. The forceps are directed to the biopsy site  and a representative sample is taken. Today, this still remains a valuable tool for the otolaryngologist, but requires skill and patience on the part of the otolaryngologist and patient.


With the introduction of flexible channeled endoscopes or flexible endoscopes with a channeled sheath (Medtronic ENT, Jacksonville, FL), the procedure has become considerably better tolerated by patients and easier to perform. The patient is anesthetized and positioned similarly to the previous descriptions. The flexible laryngoscope is passed transnasally and held in position viewing the biopsy target. A 2.0-mm flexible cup forceps is introduced by an assistant through the channel of the endoscope or the endosheath until they appear several millimeters beyond the tip of the scope (Fig. 15) (Olympus Biopsy Forceps, SB-34C-1, 1.8 mm diameter, 1050

mm length. Olympus America, Center Valley, PA). The forceps are opened and then the endoscope is advanced onto the target. The assistant closes the forceps and the sample is taken. The specimen can be withdrawn via the forceps, leaving the endoscope in place most of the time, which facilitates a rapid additional biopsy if needed. If the biopsy tissue is very large, then the entire endoscope can be withdrawn, allowing the specimen to be placed in the collection cup without being withdrawn through the working channel.


When combined with transnasal esophagoscopy and bronchoscopy, awake panendoscopy, staging, and biopsy has become a reality. Awake laryngeal biopsy and tumor staging has been demonstrated to be equally as effective as operative staging.83,107 Time from presentation to initiation of treatment is reduced by elimination of the traditional panendoscopy and biopsy under general anesthesia. Patients are spared from additional general anesthesia, physician efficiency is improved, and healthcare costs are reduced. Additional value of awake laryngeal biopsy lies in the evaluation and surveillance of laryngeal lesions that do not warrant operative excision, and culturing of lesions suspicious for bacterial or fungal infection.


Modifier 22 - Unusual increased procedural services - tips and reimbursement guidelines

 MODIFIER 22-UNUSUAL PROCEDURAL SERVICES


This modifier indicates that a procedure was complicated, complex, difficult, or took significantly more time than usually required by the provider to complete the procedure. Documentation should be in simple “layman terminology” and contained in the operative report. The operative report should be attached to the claim.

Payment is usually 20-30% higher. Often, reimbursement will not be increased when the EOMB is returned. Often, this means that the documentation was insufficient to support increased time and effort.


Submit this claim electronically initially unless otherwise informed by your carrier so that it is filed in a timely fashion.


Increased Procedural Services (Modifier 22)


This Clinical Payment and Coding Policy is intended to serve as a general reference guide for increased procedural services. Health care providers (i.e. facilities, physicians and other qualified health care professionals) are expected to exercise independent medical judgement in providing care to patients. This policy is not intended to impact care decisions or medical practice.


Modifications to this policy may be made at any time. Any updates will result in an updated publication of this policy.


Description:


Modifier 22 is described by the American Medical Association’s (AMA) Current Procedural Technology (CPT) as identifying an increased procedural service. The CPT codebook states that “When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code.” In addition, CPT states that modifier 22 should not be reported with evaluation and management (E/M) services. 


Reimbursement Information:


Additional payment for services may be considered in very unusual circumstances when the work effort is “substantially greater” than typically required. Use modifier 22 in such an instance. Use of modifier 22 is a representation by the provider that the treatment rendered on the date of services was substantially greater than typically required. The use of modifier 22 does not guarantee additional reimbursement. Thorough documentation indicating the substantial amount of additional work and reason for this work will be required for review. Reasons for additional work may include:


* Increased intensity

* Increased time

* Technical difficulty

* Severity of the patient’s condition

* Physical and mental effort

Documentation should provide the plan’s claim reviewers with a clinical picture of the patient; the procedures/services performed and support the use of modifier 22. A brief letter or statement is not a part of the medical record and is not sufficient to justify the use of modifier 22. Modifier 22 is not justified by generalized or conclusory statements including but not limited to the following:

* Surgery took additional two hours

* This was a difficult procedure

* Surgery for an obese patient


Additional Information:


* The additional difficulty of the procedure should be detailed in the body of the operative report.

* Modifier 22 should not be appended to a procedure/service if the additional work performed has a specific procedure code.

* Modifier 22 should only be reported with procedure codes that have a global period of 0, 10, or 90 days


Codes and Definitions


Modifier 22

Increased Procedural Services: When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier

22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time,

technical difficulty of procedure, severity of patient’s condition, physical and mental effort required).

Note: This modifier should not be appended to an E/M service.


Coding Guidelines


Modifier -22 identifies a service that required substantially greater effort than usually required and well outside of the range typically needed. Per the AMA, any time the modifier -22 is used, when filing an insurance claim, the operative report should be sent along with the claim to indicate and justify the unusual service. The medical record documentation must support both the substantial additional work and the reason for the additional work (e.g. increased intensity, time, technical difficulty of procedure, severity of the patient’s condition, physical and mental effort required).

Inappropriate Use of Modifier -22

• Do not use when a listed procedure code is available to describe the service performed.

• Do not use modifier 22 in combination with an E/M service.

• Do not use modifier 22 in combination with an unlisted procedure code.

• Do not use modifier 22 in combination with anesthesia codes. Additional time units are

used to report the duration of the procedure. Additional effort and complexity are otherwise reported using anesthesia physical status modifiers.

 

UNUSUAL PROCEDURAL SERVICES


When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier 22 to the usual procedure number.

A report may also be appropriate. Using the Modifier Correctly


• The 22 modifier is appended to the basic CPT procedure code when the service(s) provided is greater than usually required for the listed procedure. Use of

modifier 22 allows the claim to undergo individual consideration.


• Modifier 22 is used to identify an increment of work that is infrequently encountered with a particular procedure and is not described by another code.


• The frequent reporting of modifier 22 has prompted many carriers to simply ignore it. When using modifier 22, the claim must be accompanied by documentation and a cover letter explaining the unusual circumstances. Documentation includes, but is not limited to, descriptive statements identifying the unusual circumstances, operative reports (state the usual time for performing the procedure and the prolonged time due to complication, if appropriate), pathology reports, progress notes, office notes, etc. Language that indicates unusual circumstances would be difficulty, increased risk, extended, hemorrhage, blood loss over 600cc, unusual findings, etc. If slight extension of the procedure was necessary (a procedure extended by 15–20 minutes) or, for example, routine lysis of adhesions was performed, these scenarios do not validate the use of the modifier 22.


• Surgical procedures that require additional physician work due to complications or medical emergencies may warrant the use of modifier 22 after the surgical

procedure code.


• Modifier 22 is applied to any code of a multiple procedure claim, regardless of whether that code is the primary or secondary procedure. In these instances, the

Medicare carrier first applies the multiple surgery reduction rules (e.g., 100 percent, 50 percent, 50 percent, 50 percent, 50 percent). Then, a decision is made

as to whether or not payment consideration for modifier 22 (unusual circumstances) is in order. For example, if the fee schedule amounts for procedures A,

B, and C are $1000, $500, and $250 respectively, and a modifier 22 is submitted with procedure B, the carrier would apply the multiple surgery payment

reduction rule first (major procedure 100 percent of the Medicare fee schedule) and reduce the procedure B (second surgical procedure) fee schedule amount

from $500 to $250. The carrier would then decide whether or not to pay an additional amount above the $250 based on the documentation submitted with

the claim for unusual procedural services, as designated by modifier 22.


Radiology UNUSUAL PROCEDURAL SERVICES


When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier 22 to the usual procedure number.

A report may also be appropriate. Note: This modifier is not to be used to report procedure(s) complicated by adhesion formation, scarring, and/or alteration of

normal landmarks due to late effects of prior surgery, irradiation, infection, very low weight (i.e., neonates and infants less than 4kg), or trauma. Using the Modifier Correctly


• Modifier 22 is appended to the basic CPT procedure code when the service(s) provided is greater than usually required for the listed procedure. Use of modifier 22 allows the claim to undergo individual consideration.

• Modifier 22 is used to identify an increment of work that is infrequently encountered with a particular procedure and is not described by another code.

• Modifier 22 is generally not appended to a radiology code. If a rare circumstance does occur, submit detailed documentation with a cover letter from the

radiologist or other provider.

• The frequent reporting of modifier 22 has prompted many carriers to simply ignore it.

• Modifier 22 is used with computerized tomography (CT) numbers when additional slices are required or a more detailed examination is necessary. However,

this is subject to payer discretion. Many payers will not allow additional reimbursement for additional CT slices.

Incorrect Use of the Modifier

• Appending this modifier to a radiology code without justification in the medical record documenting an unusual occurrence. Because of its overuse, many

payers do not acknowledge this modifier.

• Using this modifier on a routine basis; to do so would most certainly cause scrutiny of submitted claims and may result in an audit.

• Using modifier 22 to indicate that the radiology procedure was performed by a specialist; specialty designation does not warrant use of the 22 modifier.

• Using modifier 22 when more x-rays views are taken than actually specified by the CPT code description. This is incorrect, especially when the code descriptor

reads “complete” (e.g., 70130, 70321, 73110, etc.). Complete means any number of views taken of the body site.

Coding Tips

• Using modifier 22 identifies the service as one that requires individual consideration and manual review.

• Overuse of modifier 22 could trigger a carrier audit. Carriers monitor the use of this modifier very carefully. The 22 modifier should be used only when sufficient documentation is present in the medical record.

• A Medicare claim submitted with modifier 22 is forwarded to the carrier medical review staff for review and pricing. With sufficient documentation of medical necessity, increased payment may result.


Pathology and Laboratory UNUSUAL PROCEDURAL SERVICES


When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier 22 to the usual procedure number.

A report may also be appropriate. Note: This modifier is not to be used to report procedure(s) complicated by adhesion formation, scarring, and/or alteration of

normal landmarks due to late effects of prior surgery, irradiation, infection, very low weight (i.e., neonates and infants less than 4 kg), or trauma.

Using the Modifier Correctly


• Modifier 22 is used to the basic CPT code book procedure code when the service(s) provided is greater than usually required for the listed procedure. Use of

modifier 22 on services requires individual consideration of the claim(s).


• Modifier 22 is used to identify an increment of work that is infrequently encountered with a particular procedure and is not described by another code.

• The frequent use of modifier 22 has prompted many carriers to ignore it. When using modifier 22, the claim must be accompanied by documentation and a

cover letter explaining the unusual circumstances. Documentation includes, but is not limited to, descriptive statements identifying the unusual circumstances,

operative reports (state the usual time for performing the procedure and the prolonged time due to any complications), pathology reports, progress notes,

office notes, etc.


Incorrect Use of the Modifier


• Appending this modifier to a code without justification in the medical record of an unusual occurrence. Because of its overuse, many payers do not acknowledge

this modifier.


• Using this modifier on a routine basis. To do so would most certainly flag the claim and may result in an audit.

• Using modifier 22 to indicate a procedure was performed by a specialist. Specialty designation does not warrant use of modifier 22. 


Coding Tips


• Using modifier 22 identifies the service as one requiring individual consideration and manual review.


• Overuse of modifier 22 could trigger a carrier audit. Carriers monitor the use of this modifier very carefully. Make sure that modifier 22 is used only when sufficient documentation is present in the medical record.


• A Medicare claim submitted with modifier 22 is forwarded to the carrier medical review staff for review and pricing. With sufficient documentation of medical necessity increased payment may result.


Medicine UNUSUAL SERVICES


When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier 22 to the usual procedure number.

A report may also be appropriate. Note: This modifier is not to be used to report procedure(s) complicated by adhesion formation, scarring, and/or alteration of

normal landmarks due to late effects of prior surgery, irradiation, infection, very low weight (i.e., neonates and infants less than 4 kg), or trauma.


Using the Modifier Correctly 


• Modifier 22 is appended to the basic CPT procedure code when the service(s) provided is greater than usually required for the listed procedure. Use of modifier 22 on services requires individual claim consideration.


• Modifier 22 is used to identify an increment of work that is infrequently encountered with a particular procedure and is not described by another code.


• The frequent reporting of modifier 22 has prompted many carriers to ignore it.

When using modifier 22, the claim must be accompanied by documentation and a cover letter explaining the unusual circumstances. Documentation includes, but is not limited to, descriptive statements identifying the unusual circumstances, operative reports (state the usual time for performing the procedure and the prolonged time due to complication), pathology reports, progress notes, office notes, etc. Some words that indicate unusual circumstances would be difficult, increased risk, extended, etc. If a slight extension of the procedure was necessary (e.g., a procedure is extended by 15–20 minutes), this minimal prolonged time does not validate the use of modifier 22.

• Surgical or medical procedures that require additional physician “work” due to complications or medical emergencies may warrant the use of modifier 22.

• Modifier 22 is used with the following codes in the medicine section of the CPT manual, when an unusual circumstance is well-documented. 


Reimbursement Guidelines

A. General

1. Moda Health does allow additional reimbursement for increased procedural services for:

a. Certain specific chemical dependency services at specific reimbursement rates only when specified in the Moda Health provider contract and requirements specified in the contract are met.

b. Surgical procedure codes, and only after manual review to determine if an additional allowance is warranted. If the review determines that an additional allowance is warranted, the procedure will be reimbursed at 125% of the normal allowance (contracted fee or maximum plan allowable).

2. Moda Health does not allow additional reimbursement for increased procedural services for the following:

a. When the contracted fee allowance is based on a percentage of billed charges.

b. For anesthesia codes.

c. For non-surgical procedure codes (with limited chemical dependency exceptions noted above). Non-surgical procedures (e.g. laboratory, radiology, medical codes, etc.) submitted with modifier 22 for increased procedural services are reimbursed at the normal allowance (contracted fee or maximum plan allowance).

B. Billing Office & Claims Submission Responsibilities

1. When modifier -22 is used to indicate increased procedural services, the documentation must be submitted for manual review before any adjustment to increase the fee allowance can be considered.

a. The billing office should supply both of the following items:

i. A concise statement about how the service differs from the usual and indicating the factors contributing to the increased difficulty of the procedure.

ii. The operative report for the service.

b. The concise statement or brief cover letter is not a part of the medical record. This statement alone is not sufficient to support the need for an increased allowance, but assists in the review process by summarizing and directing our attention to what will be found in the operative report. The operative report must also be supplied and the increased difficulty and the reasons for it must be documented in the operative report.

c. It is the responsibility of the surgeon’s billing office to submit all necessary documentation.

d. The billing office may choose to submit claims with modifier 22 manually with the required supporting documentation attached, or submit the claims electronically and submit the required documentation for review upon request.

e. A prompt response to requests for medical records or additional information required for review will help to avoid unnecessary delays in adjudication of the claim.

2. If the nature, extent, and reasons for the increased work of the procedural service are not clearly documented in the record or if the documentation submitted is incomplete, the service will be reimbursed at the normal allowance (contracted fee or maximum planallowance).

C. Criteria for Surgical Codes

1. An increased allowance for surgical codes is considered warranted when two or more of the following factors are present:

a. Unusually lengthy procedure.

(Duration/time of procedure as compared with usual must be documented in the operative report, not merely on a cover letter.)

b. Excessive blood loss during the procedure.

c. Presence of an excessively large body habitus, e.g. BMI >40 (especially in abdominal surgery).

d. The delivery of twins, triplets, or other multiple gestations via cesarean delivery only of all gestations, and only if significant additional difficulty is encountered.

e. Trauma extensive enough to complicate the procedure and not billed as separate procedure codes. 

f. Other pathologies, tumors, malformations (genetic, traumatic, surgical) that directly interfere with the procedure but are not billed as separate procedure codes.

g. The services rendered are significantly more complex than described for the submitted CPT or HCPCS code, and there is not another, more appropriate code that describes the additional work or complexity involved.

2. An increased allowance for surgical codes is NOT considered warranted for:

a. The use of a robotic assisted surgery device.

b. Use of computer assisted navigation device.

c. Lysis of adhesions in the absence of any other factors. Lysis or division of an average amount of adhesions is included in the RVU for surgical procedures. Thus, the allowance for the primary surgical procedure(s) includes the work involved in lysis of adhesions.

d. The vaginal delivery of twins, triplets, or other multiple gestations, or a combination of vaginal delivery of at least one fetus followed by cesarean delivery of one or more additional gestations. Appropriate maternity procedure codes are available for use to properly report this situation.

e. Solely for a complication.

f. Solely for a lengthy procedure due to the surgeon’s choice of approach.

i. If the original approach fails and must be converted to another approach, then only the successful approach is reportable12, and the increased work and time due to the first attempted approach does not warrant an increased allowance.

Example:

The surgeon elects a laparoscopic cholecystectomy, but is unable to complete the procedure laparoscopically and must convert to an open cholecystecomy. The

increased time spent on the attempted laparoscopic approach does not warrant an increased allowance.

ii. If the original approach does not fail, but proves more difficult and requires additional time and effort to complete without converting to another approach, or

otherwise results in an intraoperative complication, then the increased work due to the surgeon’s choice of approach does not warrant an increased allowance.

Example:

If the surgeon elects a vaginal approach for a hysterectomy which results in additional work that would not have been considered increased procedural work substantially greater than typically required for an abdominal hysterectomy, then the increased work due to the vaginal approach does not warrant an increased

allowance.

g. A “reoperation” when the patient has had a prior surgery which does not significantly increase the difficulty of the current surgery.

h. A “reoperation” when a specific procedure code is available to specify that the procedure is a reoperation.

i. Modifier 63 and modifier 22 may not be reported on the same code.

D. Criteria for Maternity/Delivery Codes

1. An increased allowance for maternity/delivery codes is sometimes, but not always, considered warranted for a cesarean delivery (not VBAC attempt) of multiple gestations (e.g. twins, triplets, etc.).

a. Modifier 22 is not automatically warranted when multiple gestations are delivered by cesearean. CPT code 59510 (Routine obstetric care including antepartum care,

cesarean delivery, and postpartum care) includes delivery of all babies in multiple gestations, according to instructions from the AMA. (AMA14, Moda B)

b. If there is significant extra difficulty involved with delivering the additional baby/babies, then append modifier -22 and submit an explanation of the significant

extra difficulty involved and send a copy of the op report with claim. (AMA14, Moda B) The operative report must also support and document the significant extra

difficulty involved.

2. An increased allowance is not considered warranted for delivery of multiple gestations (e.g. twins, triplets, etc.) with a failed VBAC and delivery of all babies by cesarean.

a. Delivery of the first baby is coded with 59618 (Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted

vaginal delivery after previous cesarean delivery).

b. Delivery of the subsequent newborns are separately coded. See RPM020, section K. (Moda B)

3. An increased allowance for maternity/delivery codes is not considered warranted for the following items or procedures. (This list is not exhaustive; see RPM020. (Moda B)) 

These are considered part of the global maternity package, and payment is included in the RVU allowance for the delivery/global maternity procedure codes:

a. An episiotomy and repair with a vaginal delivery.

b. Repair of cervical, vaginal or perineal lacerations. (AMA14, 15, 16)

c. Exploration of the uterus.

d. Artificial rupture of membranes (AROM) before delivery.

e. Induction of labor with pitocin or oxytocin.

f. A rapid or precipitous delivery.

g. A high-risk pregnancy. (High-risk pregnancies generate additional antepartum visits above the standard antepartum schedule which are separately reportable, and

additional diagnostic procedures which are separately reported.)


Medicare ACO - Accountable care Organizations - All the update and Guideline

 Accountable Care Organizations (ACOs)

What is an ACO?


ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to their Medicare patients.


The goal of coordinated care is to ensure that patients get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.


When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, the ACO will share in the savings it achieves for the Medicare program.


Shared Savings Program


The Medicare Shared Savings Program (Shared Savings Program) offers providers and suppliers (e.g., physicians, hospitals, and others involved in patient care) an opportunity to create an Accountable Care Organization (ACO). An ACO agrees to be held accountable for the quality, cost, and experience of care of an assigned Medicare fee-for-service (FFS) beneficiary population. The Shared Savings Program has different tracks that allow ACOs to select an arrangement that makes the most sense for their organization.


The Shared Savings Program is an important innovation for moving the Centers for Medicare & Medicaid Services' (CMS') payment system away from volume and toward value and outcomes. It is an alternative payment model that:


Promotes accountability for a patient population.

Coordinates items and services for Medicare FFS beneficiaries.

Encourages investment in high quality and efficient services.


Are ACOs just a new type of health plan? Not really.



Medicare has three main payment approaches for health care services: FFS, Medicare Advantage, and ACOs.

Under Medicare Advantage, CMS contracts with health plans, which receive a monthly fee to cover services to

beneficiaries. With ACOs, CMS contracts with health care providers, which manage performance risk (i.e., cost

and quality) for a specific patient population. (See Table 1 for key differences between the programs.)



ACO Providers and Suppliers

Eligible ACO providers and suppliers that may participate in the Shared Savings Program include:


ACO professionals in group practice arrangements

Networks of individual practices of ACO professionals

Partnerships or joint venture arrangements between hospitals and ACO professionals

Hospitals employing ACO professionals

Critical Access Hospitals (CAHs) that bill under Method II

Federally Qualified Health Centers (FQHCs)

Rural Health Clinics (RHCs)

Teaching hospitals that have elected to receive payment on a reasonable cost basis for the direct medical and surgical services of their physicians

Care Coordination

Health care providers have reported that a lack of information is a barrier to improving care coordination. While a provider may know about the services they provide to the beneficiary, they often do not know about all the services the beneficiary receives from other health care providers.


To better treat patients and to coordinate their care, Shared Savings Program ACOs may request Medicare claims information about their patients from CMS.


Difference between Medicare HMO and ACO


Provider Participation

To participate in the Shared Savings Program, Medicare-enrolled providers and suppliers must form or join an ACO, and the ACO must apply and be accepted to the Shared Savings Program. Providers and suppliers may contact other ACO participants in the region, state, or national professional associations to investigate opportunities to join an ACO. ACOs must have at least 5,000 Medicare fee-for-service (FFS) beneficiaries assigned to their ACO in each benchmark year to be eligible for participation in the Shared Savings Program.


ACO - Other Entities Frequently Asked Questions


Q1. May our practice taxpayer identification number (TIN) affiliate with an Accountable Care Organization (ACO) as an “other entity” instead of as an ACO participant, even though our practice TIN is Medicare-enrolled?


Yes, a Medicare-enrolled entity may enter into an agreement with an ACO as an “other entity.” Regulations governing the Medicare Shared Savings Program (Shared Savings

Program) do not require “other individuals or entities performing functions or services related to ACO activities” to be non-Medicare enrolled individuals or entities.



Q2. If our practice signs an agreement with an ACO as an “other entity,” must our practice be exclusive to a single Shared Savings Program ACO?


No, “other entities” are not required to be exclusive to a single Shared Savings Program ACO. “Other entities” do not appear on the certified ACO Participant List and they would not be used for program operations, such as assignment.



Q3. If our practice signs an agreement with an ACO as an “other entity,” will CMS use our claims to assign beneficiaries to the ACO?


No, CMS does not use claims submitted by an “other entity” that performs functions or services on behalf of an ACO to assign beneficiaries to an ACO. CMS uses only ACO

participants that appear on the certified list submitted by the ACO for program operations, such as assignment or quality reporting sampling. Please review our ACO Participant List and Participant Agreement Guidance regarding changes in ACO participants and ACO providers/suppliers during the performance year to learn about which program operations are dependent on the certified ACO Participant List.



Q4. If our practice signs an agreement with an ACO as an “other entity,” will we qualify for Merit-based Incentive Payment System (MIPS) incentive payments under the Alternative Payment Model (APM) standard through ACO quality reporting?


No, “other entities” do not qualify for a MIPS incentive under the APM scoring standard. Only ACO participants on the certified ACO Participant List can qualify for a MIPS incentive under the APM scoring standard. “Other entities” must participate in MIPS under the regular program, including reporting quality data under one of the available group or individual reporting options. 


Performance Year 2021 Medicare Shared Savings Program Accountable Care Organizations – Map


https://data.cms.gov/Special-Programs-Initiatives-Medicare-Shared-Savin/Performance-Year-2021-Medicare-Shared-Savings-Prog/hapm-gazj



Medicare-Medicaid Accountable Care Organization (ACO) Model


Medicare program -- and the health care system at large -- toward paying providers based on the quality rather than the quantity of care they provide to patients. CMS is adding the Medicare-Medicaid ACO Model to its existing portfolio of ACO initiatives, which include:


Medicare Shared Savings Program (Shared Savings Program)

Pioneer ACO Model

Next Generation ACO Model

ACO Investment Model (AIM)

Comprehensive ESRD Care (CEC) Model



CPT code 49082, 49083, 49084 - abdominal paracentesis

Procedure Code Changes and Description


• Deleted Codes

* 49080 - Peritoneocentesis, abdominal paracentesis, or peritoneal lavage (diagnostic or therapeutic); initial

* 49081 - Peritoneocentesis, abdominal paracentesis, or peritoneal lavage (diagnostic or therapeutic); subsequent


• New Codes

* 49082 – Abdominal paracentesis (diagnostic or therapeutic); without imaging guidance

* 49083 - with imaging guidance

* 49084 – Peritoneal lavage, including imaging guidance, when performed


• (Do not report 49083 or 49084 in conjunction with 76942, 77002, 77012, 77021)


Example

Diagnosis: Malignant ascites

Procedure: Therapeutic paracentesis


The patient is explained the risks, benefits, and alternatives of the procedure abdominal paracentesis for treatment of her malignant ascites. She fully understood and wished to proceed. Pre-operative sonographic images of the abdomen show a large volume of ascites with a pocket free of bowel loops with the left lower quadrant, this will be our entry point. The overlying skin was prepped and draped 2% lidocaine was utilized for local anesthetic. A 7- french sheath needle was passed via a left lower quadrant approach into the ascitic fluid. Clear, straw-colored ascitic fluid was noted. A total of 7 liters was removed. The sheath was removed; sampling was not taken to pathology. The patient tolerated the procedure well with no apparent complications.

• Correct CPT code: 49082


CPT® Procedure Code Changes


• Revised Parenthetical notes


* 49418 - Insertion of tunneled intraperitoneal catheter (eg, dialysis, intraperitoneal chemotherapy instillation, management of ascites), complete procedure, including imaging guidance, catheter placement, contrast injection when performed, and radiological supervision and interpretation, percutaneous

* 49419 - Insertion of tunneled intraperitoneal catheter, with subcutaneous port (i.e., totally implantable)

 (49420 has been deleted. To report open placement of a tunneled intraperitoneal catheter for dialysis, use 49421. To report open or percutaneous peritoneal drainage or lavage, see 49020, 49021, 49040, 49041, 49082-49084, as appropriate. To report percutaneous insertion of a tunneled intraperitoneal catheter without subcutaneous port, use 49418)



Paracentesis

*As stated in the ACR--SIR-SPR Practice Parameter for Specifications and Performance of Image-Guided Percutaneous Drainage/Aspiration of Abscesses and Fluid 

Collections:

Image-guided percutaneous aspiration is defined as evacuation or diagnostic sampling of a fluid collection using either a catheter  or a  needle during a single imaging session, with removal of the catheter or needle immediately after the aspiration.
Image-guided percutaneous drainage is defined as  the placement of a catheter using
image guidance to provide continuous drainage of a fluid collection.
*Codes 49082 and 49083 describe a puncture of the abdominal cavity with insertion of a needle or catheter to remove fluid. The catheter/needle is removed at the end of the procedure.
* Code 49082 describes an  abdominal paracentesis performed without imaging guidance.
* Code 49083 describes an abdominal paracentesis performed with imaging guidance.
* Limited sonography for localization of fluid is bundled. If localization  reveals no fluid,and the paracentesis is not performed assign code 76705.
* For 2018, the NCCI Manual notes the following revised language: “Evaluation of an anatomic region and guidance for a needle placement procedure in that anatomic region by the same radiologic modality on the same date of service may be reported separately if the two procedures are performed in different anatomic regions. For example, a physician may report a diagnostic ultrasound CPT code and CPT code 76942 (ultrasonic guidance for needle placement...) when performed in different anatomic regions on the same date of service. Physicians should not avoid these edits based on this principle by requiring patients to have the procedures performed on different dates of service if historically the evaluation of the anatomic region and guidance for needle biopsy procedures were performed on the same date of service.” -


Peritoneal Catheter Placements
• 49082 Paracentesis; Dx or Tx, w/o imaging guidance
• 49083 Paracentesis; Dx or Tx, with imaging guidance
• If does paracentesis and leaves catheter in place, use 49406 only.Do not code for the paracentesis.
• If places indwelling catheter, sends to floor for drainage, then pulls catheter on same DOS, use 49083



Paracentesis is the aspiration of fluid from the abdominal cavity. It is most often performed for ascites, which is an abnormal accumulation of peritoneal fluid caused by liver disease, cancer or other conditions. Paracentesis may be performed for diagnostic purposes, in which case only a small amount of fluid is removed. Alternatively, large volume paracentesis (removal of up to 6 liters of fluid) may be performed for therapeutic purposes. Following large volume paracentesis the patient may receive an albumin infusion to prevent electrolyte imbalance.

The following codes are used to report paracentesis:

CPT® Code Description
49082 Abdominal paracentesis (diagnostic or therapeutic); without imaging guidance
49083 . . . with imaging guidance

Remember that aspiration involves removal of the catheter or needle at the conclusion of the procedure. Do not use codes 49082-49083 for drainage procedures in which a catheter is left indwelling.

Correspondence Language Policy/Example Number 14.40000 - Misuse of column two code with column one code

For example, CPT code 49322 describes a surgical laparoscopy with aspiration of single or multiple cavities or cysts (eg, ovarian cyst). CPT code 49082 describes an abdominal paracentesis (diagnostic or therapeutic) without imaging guidance. It is a misuse of CPT code 49082 to report it in addition to CPT code 49322 at the same

patient encounter since the procedure described by CPT code 49322 includes the procedure described by CPT code 49082

Guidelines from UHC insurance 

The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. The listing of a code does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply

CPT Code Description

49082 Abdominal paracentesis (diagnostic or therapeutic); without imaging guidance

CPT 47560, 47561, 47562, 47563, 47564, 47570 and 47579

Procedure code and Description 


47560 Laparoscopy, surgical; with guided transhepatic cholangiography, without biopsy

47561 with guided transhepatic cholangiography with biopsy

47562 cholecystectomy

47563 cholecystectomy with cholangiography

47564 cholecystectomy with exploration of common duct


47570 cholecystoenterostomy

47579 Unlisted laparoscopy procedure, biliary tract



47560, 47561 have been deleted. To report laparoscopically guided transhepatic cholangiograpy with biopsy, use 47579


Select Laparoscopic Cholecystectomy with Common Bile Duct Exploration (CBDE) Procedures


Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all-inclusive list. We recommend consulting your relevant manuals for appropriate coding options.


The following codes are thought to be relevant to Laparoscopic Cholecystectomy with Common Bile Duct Exploration (CBDE) procedures and are referenced throughout this guide.


All rates shown are 2020 Medicare national averages; actual rates will vary geographically and/or by individual facility.


Physician Coding and Payment

Code Description Work Total Facility In-Facility

47564 Laparoscopy, surgical; cholecystectomy with exploration of common duct 18.00 32.48 $1,172


Medicare Hospital Inpatient Payment Rates Effective October 1, 2019 - September 30, 2020


Medicare Severity Diagnosis Related Groups (MS-DRGs) assignment is based on a combination of diagnoses and procedure codes reported. While MS-DRGs listed in this guide represent likely assignments, Boston Scientific cannot guarantee assignment to any one specific MS-DRG. MS-DRGs resulting from inpatient laparoscopic cholecystectomy with common bile duct exploration procedures may include (but are not limited to):


A Whipple-type pancreatectomy procedure (CPT codes 48150-48154) includes removal of the gallbladder. A cholecystectomy (e.g., CPT codes 47562-47564, 47600-47620) shall not be reported separately.


Description


This policy addresses coding and coverage when an operative cholangiography is performed to evaluate the biliary tract and help decide whether or not to explore the common bile duct for stones or other abnormalities.


Definitions


Operative cholangiography involves the injection of radiopaque contrast material into the cystic or common bile duct during surgery. This procedure is performed to identify various abnormalities of the biliary ductal system, often secondary to stones (calculi or choledocholithiasis) and occasionally other lesions, such as benign strictures or tumors.


Policy Statement


Frequently during cholecystectomy, an operative cholangiogram is performed to help the surgeon decide whether or not to explore the common bile duct for stones or other pathologic processes.


When one physician reports the cholecystectomy and operative cholangiography with subsequent common bile duct exploration, the services are combined under the procedure codes 47564 (laparoscopic approach) or 47610 (open/excision approach), as appropriate. If additional surgical procedures are performed during the same operative session, then the modifier 59 may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day. When modifier 59 is reported, the patient’s records must support its use in accordance with CPT guidelines.

If, however, a second physician (e.g., a radiologist) provides the formal interpretation of the operative cholangiography, then the service is eligible for coverage under codes 74300-74301 (cholangiography and/or pancreatography).


Documentation Submission


Documentation/operative report must identify and describe the procedures performed. If a denial is appealed, this documentation must be submitted with the appeal.


Coverage


Eligible surgical services will be subject to the Blue Cross fee schedule amount. Denied services will be provider liability.

The following applies to all claim submissions.


All coding and reimbursement is are subject to all terms of the Provider Service Agreement and subject to changes, updates, or other requirements of coding rules and guidelines. All codes are subject to federal HIPAA rules, and in the case of medical code sets (HCPCS, CPT, ICD), only codes valid for the date of service may be submitted or accepted. Reimbursement for all Health Services is subject to current Blue Cross Medical Policy criteria, policies found in Provider Policy and Procedure Manual sections, Reimbursement Policies and all other provisions of the Provider Service Agreement (Agreement).

In the event that any new codes are developed during the course of Provider's Agreement, such new codes will be reimbursed according to the standard or applicable Blue Cross fee schedule until such time as a new agreement is reached and supersedes the Provider's current Agreement.

All payment for codes based on Relative Value Units (RVU) will include a site of service differential and will be calculated, if appropriate, using the appropriate facility or non-facility components, based on the site of service identified, as submitted by Provider.


Coding

The following codes are included below for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement.


CPT / HCPCS Modifier: 59

ICD Diagnosis: N/A

ICD Procedure: N/A

HCPCS: 47564, 47610, 74300, 74301

Revenue Codes: N/A

Deleted Codes: N/A


LAPAROSCOPY


Surgical laparoscopy always includes diagnostic laparoscopy. To report a diagnostic laparoscopy (peritoneoscopy) (separate procedure), use 49320.


EXCISION


47600 Cholecystectomy;

47605 with cholangiography (For laparoscopic approach, see 47562-47564) 



The five-digit numeric codes and descriptions included in the Medical Reimbursement Schedule are obtained from the Physicians’ Current Procedural Terminology, copyright 1999 by the American Medical Association (CPT). CPT is a listing of descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures performed by physicians and other health care providers.


This publication includes only CPT numeric identifying codes and modifiers for reporting medical services and procedures that were selected by the Louisiana Department of Labor, Office of Workers’ Compensation. Any use of CPT outside the fee schedule should refer to the Physicians’ Current Procedural Terminology, copyright 1999 American Medical Association and any update thereto. These CPT publications contain the complete and most current listing of CPT descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures.


No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of the Physicians’ Current Procedural Terminology, copyright 1999, by the American Medical Association. All rights reserved


Maximum Fee Allowance Schedule Office of Workers' Compensation

CPT Global Maximum

Code Mod Description Days Allowance

47564 Laparo cholecystectomy explr. 90 BR



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