Upper GI endoscopy, including esophagus, stomach and either the duodenum and or jejunum as appropriate; with delivery of thermal energy to the muscle of the lower esophageal sphincter and/or gastric cardia, for treatment of GERD
Scenario 1 – Mouth & Throat Cancer (see handout) Mr. Smith is admitted to the hospital with a diagnosis of mouth and throat cancer 145.9 and 149.0 . He has a glossectomy (define: Surgical removal of all or part of the tongue.) complete with tracheostomy with unilateral radical neck dissection (41145). A gastronomy, open with construction of gastric tube is also performed (43832). The supplies for the tracheostomy and g-tube are not separately billable for the inpatient portion @ this time. When Mr. Smith is discharged his trach supplies care kit (A4629), speaking valve (L8501) and other supplies in the range of A4623-A4628 may be covered based on carrier requirements. Mr. Smith’s g-tube is for feeling and if and when it needs changing (B4086) with g/j tubing. The enteral supplies such as the feeding supply kit are in the B codes section.
Certification of medical necessity is required for coverage through most insurance companies. Depending on the method of delivery such as pump/gravity/syringe fed these are different kit codes. For example, gravity fed is B4036 for each day. Enteral nutrition is in calories per unit such as 100 cal=1 unit. If Mr. Smith is on an 800 calorie program he will receive 8 units per day. Mr. Smith is receiving blendarized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals and may include fiber (B4149).
Scenario 2 – Abdominal & Digestive Disorders (see handout) Mrs. Jones has a long history of abdominal and digestive disorders. She has GERD, diverticulitis, a bleeding ulcer. She is admitted from the ER to undergo a suture of the large intestine (colorrhapy) for perforated ulcer with colostomy (44605). [She also has 2 units of blood which we will not code here.] Post-operatively she receives all the necessary supplies and education to take care of her ostomy. Mrs. Jones has a non-Medicare primary insurance plan that reimburses for these supplies with a pre-certification call from the billing/UR office. She fills the RX in the pharmacy in 2 weeks for the following supplies: Skin barrier, 4x4 10 units (A4362), Adhesive remover (A4365) 1 unit, Ostomy pouches, drainable with faceplate attached 10 units (A4377) and Ostomy deodorant tablets 10 units (A4395). If Mrs. Jones had Medicare Primary and a supplemental/secondary plan it would also require a medical necessity form and the billing office could not bill electronically for these supplies .
Scenario 3 – Headache, Jaw Pain, Sleeping Problem (see handout) Mr. Stanley presents with complaints of headache, jaw pain, difficulty sleeping and jaw locking. Other conditions are ruled out and the diagnosis is Temporal Mandibular Joint Disease (Disorder) TMJ. Mr. Stanley also has 2 non-erupted wisdom teeth that are contributing to the problem. Mr. Stanley is treated at the minor surgery wing of the dental suite at the medical center. First, the tow impacted teeth partially boney (D7230) are extracted with nitrous oxide for anesthesia. Next, a TMJ arthroscopy (D7874) with disc repositioning and stabilization is completed (see also 29804). Mr. Stanley is discharged late that day to his home with an RX for a surgical splint (D5988) which he picks up in the prosthetic department. Mr. Stanley has BCBS and Delta Dental for insurance. All items are to be sent to Delta Dental. If Mr. Stanley had Medicare primary, the procedure would be paid with Medicare prime but Medicare does not cover the splint so that is covered by Delta Dental as primary.
Sample Billing codes and Charges Total charge Units Charge HCPCS codes 100.00 1 100.00 D5988 1000.00 1 1000.00 29804* 1000.00 1 1000.00 D7874 1000.00 2 500.00 D7230