ASGE members may submit coding inquiries electronically to codingquestions@asge.org. Each month ASGE gets dozens of questions from members. When submitting a question, please allow at least three business days for a response. When submitting inquiries, please include the ASGE member’s name and ID number. Only questions will be accepted and not reports. Below are two questions that could be beneficial to your practice.
Question #1
We have a question about endo center billing. We have been billing and getting paid, for example, using CPT codes 45385 and 45380 as two separate line items on claims for our ASC charges. We have recently merged with another group, and they do not want to do this, so it is a bit of a struggle. Are we wrong in billing like this?
Answer
You are correct. The physician and ASC charges are usually mirror images, with the exception of modifier 53 for the physician and modifier 74 for the facility, and the multiple endoscopy policy established by Medicare in 1993 allows for billing for multiple endoscopic procedures within the same family of endoscopy charges as long as it’s done with a separate technique to a separate lesion. National Correct Coding Initiative (CCI) policy, chapter 6, section H, #25 supports this billing. Most payers follow CCI policy, and those who don't follow McKesson policy, which is only found on the payer website and accessed through it. There are some contractual policies that only allow the ASC to get paid for the most extensive procedure but that does not apply to all payers.
Question #2
A patient presented to the ER due to swallowing a foreign body. Patient's classification per the hospital is emergency. We were called in and did an abbreviated history and physical examination (H&P) and then scoped the patient to remove the foreign body. Can we bill for the H&P, and if so, do we use the emergency visit codes or do we use the regular outpatient E/M codes?
Answer
The visit on the same day of the procedure is one of the top issues that the recovery audit contractors (RACs) and commercial payer auditors are reviewing. In order to bill a separate visit on the same day of a procedure, the visit has to be completely unrelated to the procedure that is being scheduled/performed that day. The relative value units (RVUs) for each procedure include a preprocedure visit/evaluation, the procedure and the post-procedure care, so just the visit to evaluate and decide to do the minor procedure is not separately billable.