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Endoscopy Billing Just Got More Complicated

If billing and reimbursement for endoscopies wasn’t already frustrating for anesthesia professionals, this year brings a multitude of changes!   The old ASA codes for endoscopy (00740 and 00810) have been deleted and replaced with several new codes (00731, 00732, 00811, 00812, 00813).

The good news is that the documentation requirements for endoscopies remain much the same.  The primary difference is that now coders are tasked with choosing from several ASA codes where there were once only two.  There are advantages and disadvantages to consider.

Upper Endoscopy

One excellent advantage is that now there is a specific code(00732) for endoscopic retrograde cholangiopancreatography (ERCP) with an elevated base unit value of 6.  Prior to 2018 ERCPs were billed using the upper endoscopy code which was only 5 base units.  Additionally, many payers require medical necessity for anesthesia for endoscopies, but not for ERCPs, however there was no way, other than diagnosis and appealing with records, to differentiate between an EGD and ERCP.  Now, there will be no question that the procedure being done is an ERCP. 

All other upper endoscopies (excluding rigid - 00320) are billed with a separate ASA code (00731) valued at 5 base units. 

Lower Endoscopy

A disadvantage pops up in the lower endoscopy procedures.  There is now an ASA code specifically for screening colonoscopies (00812) which has a reduced base unit value of 4, (3 for Medicare).  This will cut reimbursement significantly for those practices which have a high volume of screenings. 

Colonoscopies which start as screening and turn to diagnostic during the course of the procedure, for example if polyps are found and biopsied, are now billed in two different ways.  Medicare allows for billing these with the lower endoscopy NOS code (00811 - 4 base units), while the CPT guidelines specifically state to use the screening code(00812).  Both should be billed with the screening diagnosis, Z12.11, and PT modifier to indicate that there were findings.

Combined Upper and Lower Endoscopy

There is now a specific code (00813) for both an upper and lower endoscopy done in the same session.  In the past, anesthesia coders have had to choose one procedure and there was no way to capture that both were done, other than coding all diagnoses.  This ASA code has a base unit value of 5, so there will be no loss of reimbursement.  However, it does present another new problem.  How should the service be reported when the colonoscopy portion is a screening, or screening turned diagnostic?  The jury is still out on that one.  There are no current guidelines from CMS or the AMA.

Suffice it to say, now more than ever, documenting the correct diagnoses and procedures is vital to accurate billing and reimbursement for endoscopies. 


By: Heather E. Golfos, CPC, CANPC

Coding Department Manager

On Tuesday, January 9, 2018

Categories: Compliance & Coding News

The information presented herein reflects general information that is current as of the date it was first published. Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

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