Q/A: Billing for GI Anesthesia

March 21st, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Categories:   Anesthesia|Pain Management   CPT® Coding   Insurance  
0 Votes - Sign in to vote or comment.

Q: We have CRNA’s that provide anesthesia, so we would use the following codes for the appropriate procedure being performed:

  • 00731 – EGD (5 base units)
  • 00811 – Diagnostic Colo (4 base units)
  • 00812 – Screening Colo (3 base units)
  • 00813 – Colo & EGD (combo) (5 base units)

The issue I’m having is the CPT book states to use 00812 for screening colonoscopies, regardless of the findings. One of my doctors showed me a video from the ASGE stating to use 00812 for screening and surveillance colonoscopies regardless of the findings.

But the MLN Matters (MM10181) states that if a screening colonoscopy becomes diagnostic, anesthesia services are reported with CPT code 00811 with modifier PT. Is this only for Medicare claims? I have tried to reach out to my commercial payers and cannot get a clear answer from them.

If we use the screening anesthesia code for ALL screening and surveillance colonoscopies regardless of findings, this will significantly reduce our reimbursement since the base units went from a 5 to a 3.

I’m just trying to get a clear answer as to what CPT codes should be used for the different colonoscopy scenarios.

A: Be sure to review the specific payer policy you are submitting claims to. Medicare’s policy requires the use of a different code when a screening colonoscopy becomes a diagnostic procedure requiring you to bill with CPT code 00811 when treating a Medicare Beneficiary. The use of modifier PT is also a Medicare rule, See information below from the WPS website.

With that being said, if the payer you are billing has a policy and the provider is contracted with that payer, the provider is obligated to follow the payer's policy. AMA does indeed have guidelines, but a payer may have their own rules, and if so you need to follow the payer’s rules. A lot of payers follow CMS policies and rules such as BC, OPTUM, UHC…. Regarding reaching out to your payer, the claims department will likely not be of help, However, most providers are assigned a Provider Representative that is there for the provider and staff, you should know your large provider reps by their first name.

The key is to UNDERSTAND the specific payer policies and the rules you need to follow for each payer. The AMA may have guidelines; however, your contract with specific payers may trump those guidelines. Find-A-Code has access to Commercial Payer policies you may be interested in; it is one of our most popular tools. You will improve your bottom line and ensure compliance if you have someone managing your contracts that can identify and understand the specific rules, as well as have payer policies easily available.

Don’t forget the date of Service, was the service done before particular codes went into effect? Rules may change with payers and you are expected to keep up with them and comply with the changes on the effective date of the change. In the case of an audit, payers will look at the contracts the provider has signed with them and expect compliance with their rules.

Modifier PT: A colorectal cancer screening test which led to a diagnostic procedure

Appropriate Usage:

  • When a service began as a colorectal cancer screening test and then was moved to diagnostic test due to findings during the screening
  • Practitioners should append the modifier to the diagnostic procedure code that is reported instead of the screening colonoscopy or screening sigmoidoscopy HCPCS code
  • Append to procedure codes in the range: 10000 to 69999

Inappropriate Usage:

  • Do not use the Modifier PT when the service began as a diagnostic procedure
  • On any other procedure outside the range listed above

CMS Resources:

CMS Medicare Learning Network Matters Article MM7012

http://www.cms.gov/MLNMattersArticles/downloads/MM7012.pdf

Note: The Medicare policy is that the deductible is waived for all surgical procedures furnished on the same date and in the same encounter as a colonoscopy, flexible sigmoidoscopy, or barium enema that were initiated as colorectal cancer screening services.

Modifier PT Fact Sheet

References:

WPS - Government Health Administrators- Modifier PT Fact Sheet

As per CMS MLN- MM10181:

Anesthesia services furnished in conjunction with and in support of a screening colonoscopy are reported with CPT code 00812 (Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy). CPT Code 00812 will be added as part of January 1, 2018, HCPCS update.

Effective for claims with dates of service on or after January 1, 2018, Medicare will pay claim lines with new CPT code 00812 and waive the deductible and coinsurance. When a screening colonoscopy becomes a diagnostic colonoscopy, anesthesia services are reported with CPT code 00811 (Anesthesia for lower intestinal endoscopic procedures, endoscopy introduced distal to duodenum; not otherwise specified) and with the PT modifier. CPT code 00811 will be added as part of January 1, 2018, HCPCS update.

Effective for claims with dates of service on or after January 1, 2018, Medicare will pay claim lines with new CPT code 00811 and waive only the deductible when submitted with the PT modifier.

Codapedia Forum

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Comments

Apr 10th, 2018 - rphelps

Billing for GI Anesthesia

For Medicare only if a screening turn diagnostic I use the 00811PT. All others 00812. No problem with payments.

0 Votes - Sign in to vote.

Latest articles:  (any category)

Billing and Documenting for Therapeutic Exercises versus Therapeutic Activities
July 13th, 2022 - Dr. Evan M. Gwilliam, DC, MBA, QCC, CPC, CCPC, CPMA, CPCO, AAPC Fellow, Clinical Director
Chiropractors treat, among other things, issues with the musculoskeletal system. Active therapeutic procedures are accepted as effective ways to treat many common conditions and therefore can be billed and generate revenue for a clinic. Two common CPT codes that might be used in a chiropractic setting include:
Medicare Advantage (MA) Benchmarking Policies Are Headed for Change
July 12th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
More than 43% of Medicare beneficiaries are not enrolled in Medicare Advantage plans, which were established to control costs and improve quality. However, as noted in the March MedPac Report Executive Summary of 2021, these plans average an estimated 104% of Medicare Fee-For-Service (FFS) spending. How does CMS plan to manage Medicare Advantage plans now?
How Extensions to the COVID-19 Public Health Emergency Affect Healthcare Reimbursement
June 28th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Providers need to begin preparations for how to handle a return to pre-COVID-19 public health emergency (PHE) policies. As the saying goes, "you can't put the rabbit back in the hat." Some COVID-19 PHE policies are so well liked it will be very difficult for the government to return to pre-COVID-19 policies. For now, we have at least the promise of a 60-day notice to all governors precipitating the end of the PHE.
Why You Should Be Using The Two-Midnight Rule
June 23rd, 2022 - David M. Glaser, Esq.
Are you using something other than two-midnight? Here’s why you shouldn’t be. Is there the possibility that your utilization management team and physician advisors are applying InterQual, MCG, or any other utilization tool other than the two-midnight rule to your Medicare admissions? Over the last few months, it has...
Q/A: Service Period for 99490
June 6th, 2022 - Chris Woolstenhulme
Question: If CCM hours/work is to be billed monthly, and CCM tasks are done daily throughout the month, should it be saved until the end of the month to bill, and should each date be billed as DOS in one claim? Answer: According to CMS, “The service period for CPT 99490 ...
Reporting CCM and TCM Codes with E/M Codes
June 1st, 2022 - Chris Woolstenhulme
When reporting CCM or TCM codes, you will only get reimbursed for what is allowed. The E/M office visits can be coded in addition but are not interchangeable with CCM codes. You can bill an E/M visit during the time a patient is under Care Management, however, you can’t count time ...
Q/A: Billing Over the Allowed Amount
June 1st, 2022 - Chris Woolstenhulme
Question: Is there a financial penalty for billing over the allowed amount? Answer: Yes, if you are submitting claims to a contracted provider, you cannot bill over the contracted amount of your fee schedule. This is called balanced billing. There is also the no-surprise rule that protects insured and non-insured or ...



Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2022 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association