Chapter 13: 2015 Coding Updates

Youll reduce the amount of times you use modifier 52 for GI procedures.
If you want to avoid headaches starting in the new year, then you need to immerse yourself in the significant changes
to coding for lower GI endoscopic procedures in CPT 2015. These changes are consistent with similar changes made
to upper GI endoscopy codes in CPT 2014. These revisions also conclude a concerted effort to standardize the
terminology of the GI endoscopy codes.
Descriptor Edits Changes the Way You Will Report GI Procedures
The CPT Editorial Panel continues to standardize the language and make the code descriptors more accurate in lower
GI endoscopy procedures. This will affect codes across the lower GI spectrum with changes in:
Base codes: The panel has continued with the standardization of the code descriptor by replacing the terminology
with or without in the codes with including, when performed. This is similar to what was done to upper GI
procedures (see CPT 2015 Part 1: Non-Inclusive Diverticulitis Drives New Esophagoscopy Changes featured in the
Gastroenterology Coding Alert volume 16 number 11). This particular change is applicable for the base codes of
endoscopy families.

Code 44360 gets updated from Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not
including ileum; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)
to Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; diagnostic,
including collection of specimen(s) by brushing or washing, when performed (separate procedure)
Similarly, code 44380 will read as Ileoscopy, through stoma; diagnostic, including collection of specimen(s) by
brushing or washing, when performed (separate procedure)
Code 44385 will be described as Endoscopic evaluation of small intestinal pouch (eg, Kock pouch, ileal reservoir [S
or J]); diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
Code 44388 for stomal colonoscopy will now read as Colonoscopy through stoma; diagnostic, including collection of
specimen(s) by brushing or washing, when performed (separate procedure)
Code 45330 updates to Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or
washing, when performed (separate procedure)
Code 45378 will read as Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or
washing, when performed (separate procedure).

Keep in mind that the changes in descriptor language do not affect the usage the above codes in any way. The
changes are just a continuation in standardization of the language.
Foreign body removal: You also have to implement descriptor changes for removal of foreign body, which effectively
specifies that from next year onward, you will be reporting foreign body removal only once even if the physician
removed multiple bodies in the same session. Code 45332 will change to Sigmoidoscopy, flexible; with removal of
foreign body[s]. Similar changes will affect 44363 (Small intestinal endoscopy, enteroscopy beyond second portion of
duodenum, not including ileum; with removal of foreign body[s]), 44390 (Colonoscopy through stoma; with removal of

CPT 2014 American Medical Association. All rights reserved.

foreign body[s]), and 45379 (Colonoscopy, flexible; with removal of foreign body[s]).

Control of bleeding: The panel has replaced all previous code descriptors for control of bleeding codes (such as
injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, and plasma coagulator) with a single term any
method. For example, 44391 will change to Colonoscopy through stoma; with control of bleeding, any method.
Similarly updated codes are 45334 (Sigmoidoscopy, flexible; with control of bleeding, any method) and 45382
(Colonoscopy; with control of bleeding, any method).

Stent placement: The new lower GI endoscopy codes for placement of endoscopic stents will now include predilation, post-dilation, and guide wire passage, whereas you currently consider only pre-dilation. You will not report
modifier 52 (Reduced services), even if the GI does not perform all the three components during the same session and
you will not be allowed to report these separately also. All old stent related codes stand deleted and new codes
reflecting the change have been introduced instead. For instance, CPT deletes 44383 and replaces it with new code
44384 (Ileoscopy, through stoma; with placement of endoscopic stent [includes pre- and post-dilation and guide wire
passage, when performed]) takes its place. Similarly, 44402 will replace 44397 (Colonoscopy through stoma; with
transendoscopic stent placement [includes predilation]); 45347 will replace 45345 (Sigmoidoscopy, flexible; with
transendoscopic stent placement [includes predilation]); and new code 45389 replaces 45387 (Colonoscopy, flexible,
proximal to splenic flexure; with transendoscopic stent placement [includes predilation]).

Ablation: New codes for ablation procedures follow the same changes done to stent procedures and will include preand post-dilation and guide wire passage, when performed. Separate reporting of pre- or post-dilation or guide wire
passage will be rejected due to bundling. For instance, you will delete 44393, and youll add new code 44401
(Colonoscopy through stoma; with ablation of tumor [s], polyp[s], or other lesion[s] [includes pre-and post-dilation and
guide wire passage, when performed]). Similarly, new codes 45346 and 45388 replace 45339 (Sigmoidoscopy, flexible;
with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or
snare technique) and 45383 (Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or
other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique) respectively.

Bipolar cautery: CPT 2015 has also modified tumor removal codes by taking out the reference to bipolar cautery.
For example, 44392 will become Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by
hot biopsy forceps in accordance with the latest techniques being used for growth removal. Similar modifications can
be seen to 45333 (Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps)
and 45384 (Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps).
Therefore, from January onward, you will have to use codes for unlisted procedures to report use of bipolar cautery.

New Introductions in Colonoscopy Codes Expands the Family

The CPT Editorial Panel has now defined colonoscopy as the examination of the whole colon because CPT 2015
removes the phrase proximal to splenic flexure from the official descriptor for code 45378 (Colonoscopy, flexible,
proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or
without colon decompression [separate procedure]), which indicates the procedure applies to the entire colon, rather
than just a specific portion.

CPT 2014 American Medical Association. All rights reserved.

Other than changing the descriptors of the existing codes, CPT 2015 introduces new codes for transendoscopic
balloon dilation and endoscopic mucosal resection. So, if your physician performs a simple endoscopy and has to use
balloon dilation for the simple purpose of better visualization, you will be able to report this new code 44381
( Ileoscopy,through stoma; with transendoscopic balloon dilation). CPT 2015 has introduced a similar code for
colonoscopy 44405 (Colonoscopy through stoma; with transendoscopic balloon dilation).

Get ready for new codes describing endoscopic mucosal resection (EMR) including injection-assisted, cap-assisted, and
ligation-assisted techniques. CPT has now bundled sub-mucosal injection, banding, or snare polypectomy for the
same lesion into the code for EMR. Moreover, you will not report a biopsy if your gastroenterologist performs it on the
same lesion as the EMR. The new codes are 44403 (Colonoscopy through stoma; with endoscopic mucosal resection),
45349 (Sigmoidoscopy, flexible; with endoscopic mucosal resection), and 45390 (Colonoscopy, flexible; with
endoscopic mucosal resection).
Colonoscopy via stoma has been brought at par with flexible colonoscopy with new codes for area-specific ultrasound
procedures (with/without fine needle aspiration/biopsy). The new code for colonoscopy via stoma is 44406 (with
endoscopic ultrasound examination, limited to the sigmoid, descending, transverse, or ascending colon and cecum and
adjacent structures). The corresponding flexible colonoscopy code 45391 has been updated to with endoscopic
ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and
adjacent structures.

CPT 2015 has recognized decompression procedures in endoscopies by adding new codes in colonoscopy (flexible
and through stoma) and modifying an existing one in sigmoidoscopy. The new codes are 44408 (Colonoscopy through
stoma; with decompression [for pathologic distention] [eg, volvulus, megacolon], including placement of
decompression tube, when performed) and 45393 (Colonoscopy, flexible; with decompression [for pathologic
distention] [eg, volvulus, megacolon], including placement of decompression tube, when performed). The modified
sigmoidoscopy code 45337 will be used as Sigmoidoscopy, flexible; with decompression (for pathologic distention)
(eg, volvulus, megacolon), including placement of decompression tube, when performed.

Provision for Unlisted Procedures Keeps Space for Emerging technology

CPT 2015 has kept a provision for unlisted procedures for procedures not yet coded. You will find that 44799
(Unlisted procedure, small intestine) will now be much more specific with the code being confined to the small
intestine. A similar area-specific unlisted procedure has been added with 45399 (Unlisted procedure, colon).

Modifiers: CMS Unveils 4 New Modifiers to Offset

Unwarranted Use of 59
Judicious selection and not playing safe will be the key terms for future.
Popularity can be a great thingunless the OIG is watching. Thats when you dont want to run with the crowd. Such
has been the case with modifier 59, which CMS describes as the most widely used HCPCS modifier, and intends to

CPT 2014 American Medical Association. All rights reserved.

stop that by introducing four modifiers to take its place in specific circumstances.
As most coders are aware, modifier 59 (Distinct procedural service) can separate CCI edits, but it is not meant to be
utilized solely for that reason. In fact, CMS says in Transmittal R1422 (issued on Aug. 15) that many providers misuse it
for this purpose, leading the modifier to be the source of a projected one-year error rate of $770 million.
CMS points out the following three common reasons that people use modifier 59, along with the associated error odds,
according to MLN Matters article MM8863, issued on Aug. 15:

Infrequently used to identify a separate encounter, typically used correctly

Less commonly utilized to define a separate anatomic site, less often used correctly
Commonly used to define a distinct service, but frequently done so incorrectly

Say Hello to EPSU Modifiers

In light of the problems that CMS has faced when dealing with modifier 59, CMS felt the need to find a solution. The 59
modifier often overrides the edit in the exact circumstance for which CMS created it in the first place, the MLN Matters
article says. CMS believes that more precise coding options coupled with increased education and selective editing is
needed to reduce the errors associated with this overpayment.
To that end, CMS has debuted the following new modifiers, known as the X(EPSU) modifiers:

XE: Separate encounter (A service that is distinct because it occurred during a separate encounter)
XS: Separate structure (A service that is distinct because it was performed on a separate organ/structure)
XP: Separate practitioner (A service that is distinct because it was performed by a different practitioner)
XU: Unusual non-overlapping service (The use of a service that is distinct because it does not overlap usual
components of the main service)

Although the new modifiers will replace modifier 59 in specific instances, CMS wont cease accepting -59 in 2015. CMS
will not stop recognizing the 59 modifier but notes that CPT instructions state that the 59 modifier should not be used
when a more descriptive modifier is available, says the Transmittal, which has an effective date of Jan. 1, 2015. CMS
will continue to recognize the 59 modifier in many instances but may selectively require a more specific X(EPSU)
modifier for billing certain codes at high risk for incorrect billing.
For instance, CMS is eventually going to institute edits that will allow the XE modifier to separate a specific CCI edit
pair, but wont accept modifier 59 or XU to separate that particular pair. As a way of easing into the new modifiers,
CMS will initially accept either modifier 59 or the X(EPSU) modifier for a service, but the rapid migration of providers to
the more selective modifier is encouraged, the MLN Matters article notes. However, MACs can start requiring the more
specific modifiers in place of modifier 59 at their convenience, so keep an eye out for local requirements.
Keep in mind that CMS does not want you to play it safe and just add all of the modifiers to each CCI edit youre trying
to separate. Therefore, you cant report both the 59 modifier and an X(EPSU) modifier on the same line item.

- Published on 2015-01-01

CPT 2014 American Medical Association. All rights reserved.