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2009 Procedural Reimbursement Guide

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  • 1. 2009 Procedural Reimbursement GuideSelect Gastroenterology Procedures This Procedural Reimbursement Guide for select gastroenterology procedures provides coding and reimbursement information for physicians and facilities. The codes included in this guide are intended to represent typical gastroenterology procedures where there is: 1) at least one device approved by the U.S. Food and Drug Administration (FDA) for use in the listed procedure; and 2) specific procedural coding guidance provided by a recognized coding or reimbursement authority such as the American Medical Association (AMA) or the Centers for Medicare and Medicaid Services (CMS). This guide is in no way intended to promote the off label use of The Medicare reimbursement amounts shown are medical devices. currently published national average payments. Actual reimbursement will vary for each provider and Please note that while these materials are intended institution for a variety of reasons including to provide coding information for a full range of geographic difference in labor and non-labor costs, endoscopy procedures, the FDA approved/cleared hospital teaching status, and/or proportion of labeling for all products will not be consistent with all low-income patients. Please feel free to contact uses described in these materials. Some payers, Boston Scientific reimbursement department if you including some Medicare contractors, may treat a have any questions about information in these procedure which is not specifically covered by a materials. You can find reimbursement updates on products FDA-approved labeling as a non-covered our website, service. www.bostonscientific.com/reimbursement.Important – Please Note: Reimbursement information provided by Boston Scientific Corporation is gathered from third-party sources and is presented forillustrative purposes only. This information does not constitute reimbursement or legal advice. Boston Scientific makes no representation or warrantyregarding this information or its completeness, accuracy, timeliness, or applicability with a particular patient. Boston Scientific specifically disclaims liability orresponsibility for the results or consequences of any actions taken in reliance on information in this document. Boston Scientific encourages providers tosubmit accurate and appropriate claims for services. Laws, regulations and payer policies concerning reimbursement are complex and change frequently.Providers are responsible for making appropriate decisions relating to coding and reimbursement submissions. Accordingly, Boston Scientific recommendsthat you consult with your payers, reimbursement specialist and/or legal counsel regarding coding, coverage and reimbursement matters.If reimbursement is requested for the use of a device that could be inconsistent with (or not expressly specifiedin) the FDA cleared or approved labeling,please carefully consult with your billing advisors or payers for advice as some payers may have policies that make it inappropriate to submit claims forsuch items or related services. Boston Scientific does not promote the off-label use of our devices.
  • 2. 2009 Procedural Reimbursement Guide Endoscopy DESCRIPTION OF inpatient care. Private payers may also pay hospitals using MS-DRG-based PAYMENT METHODS systems for providing inpatient services. Each of Medicare’s 700+ MS-DRGs is assigned a single, fixed payment rate.THIS PROCEDURAL Physician Billing and Payment Medicare and most other insurers typically That payment rate reflects the average cost of caring for patients with similar reimburse physicians based on feeREIMBURSEMENT schedules tied to CPT® codes. CPT codes clinical characteristics who require similar resources (services, supplies, devices, are published by the American MedicalGUIDE FOR SELECT Association and used to report medical etc.) for their treatment during their hospital stay. One single MS-DRG services and procedures performed by or payment is intended to cover all hospitalENDOSCOPY under the direction of physicians. costs associated with treating an individual during his or her hospital stay,PROCEDURES Hospital Outpatient Billing and Payment with the exception of “professional” (e.g., Medicare reimburses hospitals for outpatient physician) charges associated withprovides coding and stays (typically stays of less than 24 hours) performing medical procedures. under Ambulatory Payment Classificationreimbursement information for groups (APCs). Medicare assigns a Free-Standing Clinic/Ambulatory procedure to an APC based on the billed Surgical Center Billing and Paymentphysicians and facilities. The CPT code. Hospitals may receive separate Many procedures are performed outsideMedicare payment amounts APC payments for each procedure done of the hospital in free-standing clinics. during the same outpatient visit. Many APCs Payments made to free-standing clinicsshown are national average are subject to reduced payment when from private insurers depend on the multiple procedures are performed on the contract the clinic has with the payer.payments. Actual same day. In most cases, the most Medicare payments to free-standing significant procedure is paid at 100% and all clinics are determined in part, by thereimbursement will vary for other procedures are subject to a 50% licensing status of the clinic. If a free- payment reduction. Physician payment for standing clinic is licensed by Medicare aseach provider and institution procedures performed in the outpatient an Ambulatory Surgical Center (ASC) it is hospital setting follows the same method eligible to be reimbursed for selectbased on geographic described above in Physician Billing and procedures provided in this setting. Notdifferences in costs, hospital Payment. all procedures that Medicare covers in the hospital setting are eligible forteaching status, and Hospital Inpatient Billing and Payment payment in ASCs. Medicare has Many insurers, including Medicare, define approved over 3,000 procedures (asproportion of low-income inpatient hospital care as an admission defined by CPT code), for which it will (typically stays of greater than 24 hours). A pay the ASC a facility fee. In 2008,patients. Please feel free to MS-DRG (Diagnosis-Related Group) is a Medicare started a 4-year transition of a system of classifying patients, based on their new ASC payment system that willcontact the Boston Scientific diagnoses and the procedures performed ultimately base ASC payments on a during their hospital stay. The Center for percentage (65%) of hospital outpatientreimbursement department if Medicare and Medicaid Services, which runs APC payments. Physician payment foryou have any questions at the Medicare program, uses MS-DRGs to procedures performed in the ASC setting determine how much to pay hospitals for follows the same method described800.876.9960 x4145. treating Medicare patients who receive above in Physician Billing and Payment. CPT is a trademark of American Medical Association. CPT Codes © 2008 American Medical Association. All rights reserved.See important information about the uses and limitations of this document on page 1. 2
  • 3. PROCEDURAL REIMBURSEMENT GUIDESelect Endoscopy Procedures Physician 2 FacilityInpatient Information effective through 9/30/2009. 3 4All other information effective through 12/31/2009. Outpatient Inpatient 2009 2009 2009 2009 Medicare Medicare Medicare Medicare National National National National Average Average Average Average Physician Physician Hospital ASC Possible MS-DRG Assignments CPT® Payment In- Payment In- Outpatient Facility Possible ICD-9-CM and 2009 Medicare National 1 6 Code Code Description office Facility Payment Payment Procedural Codes Average Inpatient PaymentBILIARYDiagnostic 51.1: 435: Endoscopic retrograde Malignancy of hepatobiliary system ERCP; diagnostic, with or without collection of cholangio- or pancreas with Major 43260 specimen(s) by brushing or washing (separate NA* $336 $1,449 $660 pancreatography Complication or Comorbidity procedure) (ERCP) (MCC5)Therapeutic $9,553 43261 ERCP; with biopsy, single or multiple NA* $354 $1,449 $660 51.11: 436: Endoscopic retrograde Malignancy of hepatobiliary system cholangiography (ERC) 43262 ERCP; with sphincterotomy/papillotomy NA* $415 $1,449 $660 or pancreas with Complication or 5 Comorbidity (CC ) ERCP; with pressure measurement of sphincter of 51.14: $6,619 43263 NA* $411 $1,449 $660 Oddi (pancreatic duct or common bile duct) Other closed 437: (endoscopic) biopsy of Malignancy of hepatobiliary system ERCP; with endoscopic retrograde removal of biliary duct or sphincter or pancreas without CC/MCC 43264 calculus/calculi from biliary and/or pancreatic NA* $499 $1,449 $660 of Oddi $5,292 ducts 441: Disorders of liver except malignancy, cirrhosis, alcoholic ERCP; endoscopic retrograde destruction, 43265 NA* $560 $1,449 $660 hepatitis with MCC lithotripsy of calculus/calculi, any method $9,239 442: Disorders of liver except ERCP; endoscopic retrograde insertion of malignancy, cirrhosis, alcoholic 43267 NA* $414 $1,449 $660 hepatitis with CC nasobiliary or nasopancreatic drainage tube $5,458 443: Disorders of liver except ERCP; endoscopic retrograde balloon dilation of malignancy, cirrhosis, alcoholic 43271 NA* $415 $1,449 $660 ampulla, biliary and/or pancreatic duct(s) hepatitis without CC/MCC $3,877 ERCP; with ablation of tumor(s), polyp(s), or other 444: 43272 lesion(s) not amenable to removal by hot biopsy NA* $414 $1,449 $660 Disorders of the biliary tract with forceps, bipolar cautery or snare technique MCCStenting $8,653 ERCP; with endoscopic retrograde insertion of 43268 NA* $421 $1,698 $736 445: tube or stent into bile or pancreatic duct ERCP; with endoscopic retrograde removal of 43269 NA* $461 $1,698 $736 Disorders of the biliary tract with CC foreign body and/or change of tube or stentFluoroscopy $5,769 No No Endoscopic catheterization of the biliary ductal 74328 $0 NA* additional additional system, radiological supervision and interpretation. payment*** payment*** 446: Endoscopic catheterization of the pancreatic No No Disorders of the biliary tract without 74329 ductal system, radiological supervision and $0 NA* additional additional CC/MCC interpretation. payment*** payment*** Combined endoscopic catheterization of the biliary No No 74330 and pancreatic ductal systems, radiological $0 NA* additional additional $4,015 supervision and interpretation. payment*** payment**** NA = Medicare has not developed a rate for the In-Office or ASC setting as the procedure is typically performed in the hospital setting. For physicians, if the contractor determines the service can be performed in-office, the procedure will be paid at the MD In-facility rate.1Source: Beebe et a l. (2008). CPT ® 2009 Professional Edition. Chicago: American Medical Association. CPT® is a registered trademark of American Medical Association. All Rights Reserved.2Source: November 19, 2008 Federal Register. MD payments calculated using the 2009 conversion factor of $36.066.3 Source: November 18, 2008 Federal Register.4 National average (wage index greater than one) MS-DRG rates calculated using the national adjusted full update standardized labor, non-labor and capital amounts ($5552.58). Source: October 3, 2008 FederalRegister.5 The patient’s medical record must support the existence and treatment of the complication or comorbidity.6Source: The Educational Annotation of ICD-9-CM, Reno, NV; Channel Publishing Ltd. Copyright 2006. Craig D. Puckett, Fifth Edition.See important information about the uses and limitations of this document on page 1. 3
  • 4. PROCEDURAL REIMBURSEMENT GUIDESelect Endoscopy Procedures Physician2 FacilityInpatient Information effective through 9/30/2009. 3 4All other information effective through 12/31/2009. Outpatient Inpatient 2009 2009 2009 2009 Medicare Medicare Medicare Medicare National National National National Average Average Average Average Physician Physician Hospital ASC Possible MS-DRG Assignments CPT® Payment In- Payment In- Outpatient Facility Possible ICD-9-CM and 2009 Medicare National 1 6 Code Code Description office Facility Payment Payment Procedural Codes Average Inpatient PaymentBIOPSY Esophagoscopy, rigid or flexible; with biopsy, Inpatient payment information not shown because the 43202 $260 $110 $572 $337 single or multiple biopsy procedure will rarely, if ever, be the primary Upper GI endoscopy; with biopsy, single or reason for a hospital admission.43239 $323 $166 $572 $392 multiple 43261 ERCP; with biopsy, single or multiple NA* $354 $1,449 $660 Biopsy of stomach; by capsule, tube, peroral (one 43600 NA* $103 $572 $337 or more specimens) Small intestine endoscopy; with biopsy, single or 44361 NA* $168 $632 $411 multiple Small intestine endoscopy, including ileum; with 44377 NA* $311 $632 $411 biopsy, single or multiple Ileoscopy, through stoma; with biopsy, single or 44382 NA* $80 $632 $356 multiple Endoscopic evaluation of small intestinal 44386 (abdominal or pelvic) pouch; with biopsy, single or $320 $120 $594 $344 multiple Colonoscopy, through stoma; with biopsy, single 44389 $370 $178 $594 $344 or multiple Proctosigmoidoscopy, rigid; with biopsy, single or 45305 $158 $70 $603 $347 multiple Sigmoidoscopy, flexible; with biopsy, single or 45331 $159 $72 $371 $259 multiple Colonoscopy, flexible; with biopsy, single or 45380 $443 $251 $594 $399 multipleDILATIONBalloon Esophagoscopy, rigid or flexible; with balloon Inpatient payment information not shown because the 43220 NA* $122 $572 $337 dilation (< 30-mm diameter) dilation procedure will rarely, if ever, be the primary Upper GI endoscopy; with balloon dilation of reason for a hospital admission. 43249 NA* $168 $572 $392 esophagus (< 30-mm diameter) Dilation of esophagus with balloon (30-mm or 43458 $362 $175 $572 $338 larger) for achalasia 45340 Sigmoidoscopy, flexible; with balloon dilation $400 $110 $603 $347 45386 Colonoscopy, flexible; with balloon dilation $616 $256 $594 $399Balloon and Rigid Esophagoscopy, rigid or flexible; with insertion of 43226 NA* $136 $572 $337 guide wire followed by dilation over guide wire Upper GI endoscopy; with dilation of gastric outlet 43245 obstruction (e.g., wire guided balloon, balloon, NA* $181 $572 $392 bougie) Upper GI endoscopy; with insertion of guide wire 43248 NA* $183 $572 $392 followed by dilation of esophagus over guide wire* NA = Medicare has not developed a rate for the In-Office or ASC setting as the procedure is typically performed in the hospital setting. For physicias,if the contractor determines the service can be performed in-office,the procedure will be paid at the MD In-facility rate.1Source: Beebe et al . (2008). CPT ® 2009 Professional Edition. Chicago: American Medical Association. CPT® is a registered trademark of American Medical Association. All Rights Reserved.2Source: November 19, 2008 Federal Register. MD payments calculated using the 2009 conversion factor of $36.066.3 Source: November 18, 2008 Federal Register.4 National average (wage index greater than one) MS-DRG rates calculated using the national adjusted full update standardized labor, non-labor and capital amounts ($5552.58). Source: October 3, 2008 FederalRegister.5 The patient’s medical record must support the existence and treatment of the complication or comorbidity.6Source: The Educational Annotation of ICD-9-CM, Reno, NV; Channel Publishing Ltd. Copyright 2006. Craig D. Puckett, Fifth Edition.See important information about the uses and limitations of this document on page 1. 4
  • 5. PROCEDURAL REIMBURSEMENT GUIDESelect Endoscopy Procedures Physician 2 FacilityInpatient Information effective through 9/30/2009. 3 4All other information effective through 12/31/2009. Outpatient Inpatient 2009 2009 2009 2009 Medicare Medicare Medicare Medicare National National National National Average Average Average Average Physician Physician Hospital ASC Possible MS-DRG Assignments CPT® Payment In- Payment In- Outpatient Facility Possible ICD-9-CM and 2009 Medicare National 1 6 Code Code Description office Facility Payment Payment Procedural Codes Average Inpatient PaymentENTERAL FEEDINGGastrostomy Tube Reposition of gastric feeding tube, through the Inpatient payment information not shown because the 43761 $118 $104 $572 $337 duodenum enteral feeding procedure will rarely, if ever, be the 44500 Introduction of long gastrointestinal tube NA* $25 $304 $186 primary reason for a hospital admission.Percutaneous Tube Placement Change of gastrostomy tube, percutaneous 43760 $312 $49 $304 $163 without imaging or endoscopic guidance Upper GI with directed placement of percutaneous 43246 NA* $242 $572 $392 gastrostomy tube Small intestinal endoscopy with placement of 44372 NA* $246 $632 $411 percutaneous jejunostomy tube Small intestinal endoscopy with conversion of 44373 percutaneous gastrostomy tube to percutaneous NA* $199 $632 $411 jejunostomy tube Insertion of gastrostomy tube, percutaneous under 49440 $1,049 $237 $572 $349 fluoroscopic guidance Insertion of duodenostomy or jejunostomy tube, 49441 $1,136 $259 $572 $349 percutaneous under fluoroscopic guidance Insertion of cecostomy or other colonic tube, 49442 $1,018 $214 $807 NA* percutaneous under fluoroscopic guidance Conversion of gastostomy tube to gastro- 49446 jejunostomy tube, percutaneous, under $951 $172 $572 $349 fluoroscopic guidance Replacement of gastrostomy tube, percutaneous 49450 $711 $69 $304 $186 under fluoroscopic guidance Replacement of duodenostomy or jejunostomy 49451 $677 $96 $304 $186 tube, percutaneous under fluoroscopic guidance Replacement of gastro-jejunostomy tube, 49452 $853 $150 $304 $186 percutaneous under fluoroscopic guidance Mechanical removal of obstructive material from gastostomy, duodenostomy, or jejunostomy (or 49460 $779 $49 $304 $186 other colonic tube), any method under fluoroscopic guidanceRFA LIVER Laparoscopy, surgical, ablation of one or more 47370 NA* $1,127 $7,909 NA* 50.24: Percutaneous 405: Pancreas, liver and shunt liver tumor(s); radiofrequency ablation of liver lesion or procedures with major complication or Ablation, one or more liver tumor(s), tissue comorbidity (MCC5) $31,319 47382 NA* $822 $7,909 NA* percutaneous, radiofrequency 50.25: Laparoscopic Ablation, open, of one or more liver tumor(s); 47380 NA* $1,316 $0 NA* ablation of liver lesion or radiofrequency 406: Pancreas, liver and shunt tissue procedures with complication orRadiology 5 50.23: Open ablation of comorbidity (CC ) $15,468 Ultrasound guidance for, and monitoring of, liver lesion or tissue 76940 $0 NA* $0 NA* parenchymal tissue ablation Computerized axial tomographic guidance for, and 77013 $0 NA* $0 NA* monitoring of, parenchymal tissue ablation 407: Pancreas, liver and shunt Magnetic resonance guidance for, and monitoring procedures $10,210 77022 $0 NA* $0 NA* of, parenchymal tissue ablation* NA = Medicare has not developed a rate for the In-Office or ASC setting as the procedure is typically performed in the hospital setting. For physicians, if the contractor determines the service can be performed in-office, the procedure will be paid at the MD In-facility rate.1Source: Beebe et al . (2008). CPT ® 2009 Professional Edition. Chicago: American Medical Association. CPT® is a registered trademark of American Medical Association. All Rights Reserved.2Source: November 19, 2008 Federal Register. MD payments calculated using the 2009 conversion factor of $36.066.3 Source: November 18, 2008 Federal Register.4 National average (wage index greater than one) MS-DRG rates calculated using the national adjusted full update standardized labor, non-labor and capital amounts ($5552.58). Source: October 3, 2008 FederalRegister.5 The patient’s medical record must support the existence and treatment of the complication or comorbidity.6Source: The Educational Annotation of ICD-9-CM, Reno, NV; Channel Publishing Ltd. Copyright 2006. Craig D. Puckett, Fifth Edition.See important information about the uses and limitations of this document on page 1. 5
  • 6. PROCEDURAL REIMBURSEMENT GUIDESelect Endoscopy Procedures Physician2 FacilityInpatient Information effective through 9/30/2009. 3 4All other information effective through 12/31/2009. Outpatient Inpatient 2009 2009 2009 2009 Medicare Medicare Medicare Medicare National National National National Average Average Average Average Physician Physician Hospital ASC Possible MS-DRG Assignments CPT® Payment In- Payment In- Outpatient Facility Possible ICD-9-CM and 2009 Medicare National 1 6 Code Code Description office Facility Payment Payment Procedural Codes Average Inpatient PaymentHEMOSTASIS/CLIPPINGControl of bleeding 42.33: Endoscopic Esophagoscopy, rigid or flexible; with control of excision or destruction of 43227 NA* $202 $572 $392 lesion or tissue of bleeding, any method esophagus 377: Upper gastrointestinal endoscopy including 44.43: Endoscopic control esophagus, stomach, and either the duodenum of gastric or duodenal Hemorrhage with Major 43255 NA* $274 $572 $392 bleeding Complication or Comorbidity and/or jejunum as appropriate; with control of 5 bleeding, any method* (MCC ) Small intestinal endoscopy, enteroscopy beyond 45.13: Other endoscopy $8,925 44366 second portion of duodenum, not including ileum; NA* $252 $632 $411 of small intestine with control of bleeding, any method* 45.43: Endoscopic Small bowel endoscopy; with control of bleeding, destruction of other lesion 44378 NA* $399 $632 $411 or tissue of large intestine any method* 378: 42.33: Endoscopic Colonoscopy through stoma; with control of excision or destruction of 44391 $479 $243 $594 $344 lesion or tissue of Hemorrhage with Complication or bleeding, any method* esophagus Comorbidity (CC5) 43.41: Endoscopic $5,576 Sigmoidoscopy, flexible; with control of bleeding, excision or destruction of 45334 NA* $158 $603 $347 lesion or tissue of stomach any method* Colonoscopy, flexible, proximal to splenic flexure; 45382 $583 $320 $594 $399 49.45: Ligation of with control of bleeding, any method* hemorrhoids 379:Ligation Hemorrhage without CC/MCC Esophagoscopy; with band ligation of esophageal 42.23: Other $4,201 43205 NA* $216 $572 $337 esophagoscopy varices 42.24: Closed Upper GI endoscopy; with band ligation of 43244 NA* $287 $572 $392 (endoscopic) biopsy of esophageal or gastric varices esophagus 432: 42.33: Endoscopic excision or destruction of 46221 Ligation of hemorrhoid(s) $216 $162 $387 $124 lesion or tissue of Cirrhosis & alcoholic hepatitis with esophagus MCC5Injection $9,323 Esophagoscopy, rigid or flexible; with injection 43.41: Endoscopic 43201 $272 $124 $572 $337 excision or destruction of sclerosis of esophageal varices 433: lesion or tissue of stomach Cirrhosis & alcoholic hepatitis with Esophagoscopy w/injection sclerosis of 43204 NA* $216 $572 $337 5 esophageal varices CC $5,216 Upper GI endoscopy; with submucosal 43236 $347 $170 $572 $392 45.16: Esophagogastro- injection(s), any substance duodenoscopy (EGD) with Upper GI endoscopy w/injection sclerosis of closed biopsy 43243 NA* $259 $572 $392 esophageal/gastric varices 434: Sigmoidoscopy; with submucosal injection(s), any 45.43: Endoscopic Cirrhosis & alcoholic hepatitis 45335 $225 $87 $371 $259 destruction of other lesion without CC/MCC substance Colonoscopy; with submucosal injection(s), any or tissue of large intestine 45381 $431 $237 $594 $399 $3,637 substance* NA = Medicare has not developed a rate for the In-Office or ASC setting as the procedure is typically performed in the hospital setting. For physicians, if the contractor determines the service can be performed in-office, the procedure will be paid at the MD In-facility rate.1Source: Beebe et al. (2008). CPT ® 2009 Professional Edition. Chicago: American Medical Association. CPT® is a registered trademark of American Medical Association. All Rights Reserved.2Source: November 19, 2008 Federal Register. MD payments calculated using the 2009 conversion factor of $36.066.3 Source: November 18, 2008 Federal Register.4 National average (wage index greater than one) MS-DRG rates calculated using the national adjusted full update standardized labor, non-labor and capital amounts ($5552.58). Source: October 3, 2008 FederalRegister.5 The patient’s medical record must support the existence and treatment of the complication or comorbidity.6Source: The Educational Annotation of ICD-9-CM, Reno, NV; Channel Publishing Ltd. Copyright 2006. Craig D. Puckett, Fifth Edition.See important information about the uses and limitations of this document on page 1. 6
  • 7. PROCEDURAL REIMBURSEMENT GUIDESelect Endoscopy Procedures Physician 2 FacilityInpatient Information effective through 9/30/2009. 3 4All other information effective through 12/31/2009. Outpatient Inpatient 2009 2009 2009 2009 Medicare Medicare Medicare Medicare National National National National Average Average Average Average Physician Physician Hospital ASC Possible MS-DRG Assignments CPT® Payment In- Payment In- Outpatient Facility Possible ICD-9-CM and 2009 Medicare National 1 6 Code Code Description office Facility Payment Payment Procedural Codes Average Inpatient PaymentPOLYPECTOMYHot Biopsy Upper gastrointestinal endoscopy; with removal of Inpatient payment information not shown because the 43250 tumor(s), polyp(s), or other lesion(s) by hot biopsy NA* $181 $572 $392 polypectomy procedure will rarely, if ever, be the primary forceps or bipolar cautery reason for a hospital admission. Small intestinal endoscopy; with removal of 44365 tumor(s), polyp(s), or other lesion(s) by hot biopsy NA* $190 $632 $411 forceps or bipolar cautery Colonoscopy through stoma; with removal of 44392 tumor(s), polyp(s), or other lesion(s) by hot biopsy $401 $210 $594 $344 forceps or bipolar cautery Proctosigmoidoscopy, rigid; with removal of single 45308 tumor, polyp, or other lesion by hot biopsy forceps $161 $75 $603 $347 or bipolar cautery Sigmoidoscopy, flexible; with removal of tumor(s), 45333 polyp(s), or other lesion(s) by hot biopsy forceps or $263 $105 $603 $347 bipolar cautery Colonoscopy; with removal of tumor(s), polyp(s), 45384 or other lesion(s) by hot biopsy forceps or bipolar $435 $260 $594 $399 cautery Snare Esophagoscopy, rigid or flexible; with removal of 43217 tumor(s), polyp(s), or other lesion(s) by snare $349 $163 $572 $337 technique Upper gastrointestinal endoscopy; with removal of 43251 tumor(s), polyp(s), or other lesion(s) by snare NA* $211 $572 $392 technique Small intestinal endoscopy; with removal of 44364 tumor(s), polyp(s) or other lesion(s) by snare NA* $214 $632 $411 technique Colonoscopy through stoma; with removal of 44394 tumor(s), polyp(s), or other lesion(s) by snare $470 $247 $594 $344 technique Proctosigmoidoscopy, rigid; with removal of single 45309 $182 $89 $603 $347 tumor, polyp, or other lesion by snare technique Sigmoidoscopy, flexible; with removal of tumor(s), 45338 $294 $136 $603 $347 polyp(s), or other lesion(s) by snare technique Colonoscopy; with removal of tumor(s), polyp(s), 45385 $500 $298 $594 $399 or other lesion(s) by snare techniqueHot Biopsy or Snare Proctosigmoidoscopy, rigid; with removal of 45315 multiple tumors, polyps, or other lesions by hot $195 $100 $603 $347 biopsy forceps, bipolar cautery or snare technique Other Esophagoscopy, rigid or flexible; with ablation of tumor(s), polyp(s), or other lesion(s), not 43228 NA* $216 $1,676 $730 amenable to removal by hot biopsy forceps, bipolar cautery or snare technique* NA = Medicare has not developed a rate for the In-Office or ASC setting as the procedure is typically performed in the hospital setting. For physicians, if the contractor determines the service can be performed in-office, the procedure will be paid at the MD In-facility rate.1Source: Beebe et al. (2008). CPT ® 2009 Professional Edition. Chicago: American Medical Association. CPT® is a registered trademark of American Medical Association. All Rights Reserved.2Source: November 19, 2008 Federal Register. MD payments calculated using the 2009 conversion factor of $36.066.3 Source: November 18, 2008 Federal Register.4 National average (wage index greater than one) MS-DRG rates calculated using the national adjusted full update standardized labor, non-labor and capital amounts ($5552.58). Source: October 3, 2008 FederalRegister.5 The patient’s medical record must support the existence and treatment of the complication or comorbidity.6Source: The Educational Annotation of ICD-9-CM, Reno, NV; Channel Publishing Ltd. Copyright 2006. Craig D. Puckett, Fifth Edition.See important information about the uses and limitations of this document on page 1. 7
  • 8. PROCEDURAL REIMBURSEMENT GUIDESelect Endoscopy Procedures Physician 2 FacilityInpatient Information effective through 9/30/2009. 3 4All other information effective through 12/31/2009. Outpatient Inpatient 2009 2009 2009 2009 Medicare Medicare Medicare Medicare National National National National Average Average Average Average Physician Physician Hospital ASC Possible MS-DRG Assignments CPT® Payment In- Payment In- Outpatient Facility Possible ICD-9-CM and 2009 Medicare National 1 6 Code Code Description office Facility Payment Payment Procedural Codes Average Inpatient PaymentPULMONARYBiopsy 31625 Bronchoscopy; with biopsy(s) $325 $167 $674 $423 32.01 180: Respiratory neoplasms with Major 31628 Bronchoscopy; with transbronchial lung biopsy, Endoscopic excision or Complication or Comorbidity (MCC5) single lobe $390 $186 $674 $423 destruction of lesion or $9,412 31632 Bronchoscopy, (rigid or flexible); with tissue of bronchus 181: Respiratory neoplasms pancreas transbronchial lung biopsy, each additional lobe (report separately in addition to code for primary $74 $53 $674 $412 with Complication or Comorbidity (CC5) $6,839 procedure)Cytology and Brush 33.23 182: Respiratory neoplasms without 31622 Bronchoscopy; diagnostic, with or without cell Other bronchoscopy CC/MCC $4,851 washing $296 $141 $674 $368 31623 Bronchoscopy; with brushing $324 $142 $674 $423 189: Pulmonary edema & respiratory 31624 Bronchoscopy; with bronchial alveolar lavage $301 $143 $674 $423 33.24 failure $7,489Stenting Closed endoscopic biopsy 193: Simple pneumonia & pleurisy with 31631 Bronchoscopy; with tracheal dilation and of bronchus; NA* $225 $1,662 $725 bronchoscopy (fiber-optic) MCC5 $7,955 placement of tracheal stent with brush biopsy of “lung”, 31636 Bronchoscopy; with tracheal/bronchial dilation and brushing or washing for 194: Simple pneumonia & pleurisy with placement of bronchial stent, initial bronchus NA* $220 $1,662 $725 specimen collection, CC5 $5,584 excision (bite) biopsy 31637 Bronchoscopy; with tracheal/bronchial dilation and placement of bronchial stent, each additional 195: Simple pneumonia & pleurisy major bronchus (report separately in addition to NA* $78 $674 $368 without CC/MCC $4,062 code for primary procedure) 31638 Bronchoscopy; with tracheal/bronchial dilation and 5 revision of tracheal or bronchial stent inserted at 196: Interstitial lung disease with MCC NA* $245 $1,662 $725 previous session $8,896 33.27Foreign Body Removal (Stent Removal) Closed endoscopic biopsy 197: Interstitial lung disease with CC5 31635 Bronchoscopy; with removal of foreign body $334 $185 $674 $423 of lung; Fiber-optic $6,103 bronchoscopy withNeedle Aspiration 198: Interstitial lung disease without fluoroscopic guidance with 31629 aspiration biopsy, trachea, main stem and/or lobar $595 $198 $674 $423 CC/MCC $4,552 biopsy, transbronchial lung 31633 Bronchoscopy, (rigid or flexible); with biopsy transbronchial needle aspiration biopsy, each 204: Respiratory signs & symptoms additional lobe (report separately in addition to $88 $66 $674 $412 $3,636 code for primary procedure) 31645 Bronchoscopy; with therapeutic aspiration of 205: Other respiratory system tracheobronchial tree (e.g., drainage of lung $291 $157 $674 $368 abscess) diagnoses with MCC5 $6,865 31.93Balloon Dilation Replacement of laryngeal 31630 Bronchoscopy; with tracheal or bronchial dilation or tracheal stent or closed reduction of fracture NA* $200 $1,662 $725 206: Other respiratory system diagnoses without CC/MCC $4,047 31631 Bronchoscopy; with tracheal dilation and placement of tracheal stent NA* $225 $1,662 $725 31.99 31636 Bronchoscopy; with tracheal/bronchial dilation and Other operations on placement of bronchial stent, initial bronchus NA* $220 $1,662 $725 trachea 98.15 Bronchoscopy; with tracheal/bronchial dilation and 31637 Removal of intraluminal placement of bronchial stent, each additional foreign body from trachea major bronchus (report separately in addition to NA* $78 $674 $368 and bronchus without code for primary procedure) incision 31638 Bronchoscopy; with tracheal/bronchial dilation and revision of tracheal or bronchial stent inserted at NA* $245 $1,662 $725 previous session* NA = Medicare has not developed a rate for the In-Office or ASC setting as the procedure is typically performed in the hospital setting. For physicians, if the contractor determines the service can be performed in-office, the procedure will be paid at the MD In-facility rate.1Source: Beebe et al. (2008). CPT ® 2009 Professional Edition. Chicago: American Medical Association. CPT® is a registered trademark of American Medical Association. All Rights Reserved.2Source: November 19, 2008 Federal Register. MD payments calculated using the 2009 conversion factor of $36.066.3Source: November 18, 2008 Federal Register.4National average (wage index greater than one) MS-DRG rates calculated using the national adjusted full update standardized labor, non-labor and capital amounts ($5552.58). Source: October 3, 2008 FederalRegister.5The patient’s medical record must support the existence and treatment of the complication or comorbidity.6Source: The Educational Annotation of ICD-9-CM, Reno, NV; Channel Publishing Ltd. Copyright 2006. Craig D. Puckett, Fifth Edition.See important information about the uses and limitations of this document on page 1. 8
  • 9. PROCEDURAL REIMBURSEMENT GUIDESelect Endoscopy Procedures Physician1 Facility2Inpatient Information effective through 9/30/2009.All other information effective through 12/31/2009. Outpatient Inpatient 2009 2009 2009 2009 Medicare Medicare Medicare Medicare National National National National Average Average Average Average Physician Physician Hospital ASC Possible MS-DRG Assignments and CPT® Payment In- Payment In- Outpat. Facility 2009 Medicare National Average Code Code Description office Facility Payment Payment Possible ICD-9-CM Procedural Codes Inpatient PaymentSTENTINGTracheobronchial Stenting 374: Digestive malignancy with Bronchoscopy (rigid or flexible); with tracheal dilation and 31.93: Replacement of laryngeal or Major Complication or Comorbidity 31631 NA* $225 $1,662 $725 placement of tracheal stent tracheal stent (MCC5) $10,952 375: Digestive malignancy with Bronchoscopy; with tracheal/bronchial dilation and placement of 31636 NA* $220 $1,662 $725 Complication or Comorbidity (CC5) bronchial stent, initial bronchus $6,965 42.81: Insertion of permanent tube Bronchoscopy; with tracheal/bronchial dilation and placement of into esophagus 376: Digestive malignancy without 31637 bronchial stent, each additional major bronchus (report NA* $78 $674 $368 CC/MCC $4,897 separately in addition to code for primary procedure) 388: GI obstruction with MCC5Biliary Stenting 51.86: Endoscopic insertion of $8,555 43268 ERCP; with endoscopic retrograde insertion of tube or stent into nasobiliary drainage tube 389: GI obstruction with CC5 NA* $421 $1,698 $736 bile or pancreatic duct $5,144 43269 ERCP; with endoscopic retrograde removal of foreign body 390: GI obstruction without and/or change of tube or stent NA* $461 $1,698 $736 51.87: Endoscopic insertion of stent CC/MCC $3,526 (tube) into bile duct 393: Other digestive systemEsophageal Stenting diagnoses with MCC5 $8,556 394: Other digestive system NA* $165 $1,698 $681 43219 Esophagoscopy; with insertion of plastic tube or stent 51.95: Removal of prosthetic device diagnoses with CC5 $5,286 from bile duct 395: Other digestive systemColonic and Duodenal Stenting diagnoses without CC/MCC 43256 Upper GI endoscopy; with stent placement NA* $246 $1,698 $767 $3,756 52.93: Endoscopic insertion of stent 435: Malignancy of hepatobiliary NA* $278 $1,698 $1,172 (tube) into pancreatic duct system or pancreas with MCC5 44370 Small bowel endoscopy; with stent placement $9,553 436: Malignancy of hepatobiliary 52.97: Endoscopic insertion of NA* $424 $1,698 $1,172 system or pancreas with CC 5 nasopancreatic drainage tube 44379 Small bowel endoscopy incl./ileum with stent placement $6,619 NA* $171 $1,698 $1,172 96.05: Other intubation of respiratory 437: Malignancy of hepatobiliary 44383 Ileoscopy with stent placement tract system or pancreas without 44397 Colonoscopy through stoma with stent placement NA* $267 $1,698 $681 CC/MCC $5,292 NA* $113 $1,698 $681 438: Disorders of pancreas except 5 45327 Proctosigmoidoscopy; with stent placement 97.05: Replacement of stent (tube) in malignancy with MCC $9,447 biliary or pancreatic duct NA* $168 $1,698 $681 439: Disorders of pancreas except 45345 Sigmoidoscopy; with stent placement malignancy with CC5 $5,686 440: Disorders of pancreas except NA* $334 $1,698 $681 malignancy without CC/MCC 45387 Colonoscopy; with stent placement $3,874 97.55: Removal of T-tube, other bileForeign Body Removal (Stent Removal) duct tube, or liver tube 441: Disorders of liver except 43215 Esophagoscopy, rigid or flexible; with removal of foreign body NA* $148 $572 $337 malignancy, cirrhosis, alcoholic hepatitis with MCC5 $9,329 442: Disorders of liver except 43247 Upper gastrointestinal endoscopy; with removal of foreign body NA* $194 $572 $392 malignancy, cirrhosis, alcoholic hepatitis with CC5 $5,458 98.02: Removal of intraluminal foreign body from esophagus without incision ERCP; with endoscopic retrograde removal of foreign body 443: Disorders of liver except 43269 NA* $461 $1,698 $736 malignancy, cirrhosis, alcoholic and/or change of tube or stent hepatitis without CC/MCC $3,877 Small intestinal endoscopy not including ileum; with removal of 444: Disorders of the biliary tract 44363 NA* $199 $632 $411 98.03: Removal of intraluminal foreign foreign body with MCC5 $8,653 body from stomach and small intestine without incision 445: Disorders of the biliary tract 45307 Proctosigmoidoscopy, rigid; with removal of foreign body $176 $88 $1,564 $640 with CC5 $5,769 98.04: Removal of intraluminal foreign 446: Disorders of the biliary tract 45332 Sigmoidoscopy, flexible; with removal of foreign body $261 $105 $371 $259 body from large intestine without without CC/MCC $4,015 incision 45379 Colonoscopy; with removal of foreign body $468 $261 $594 $399* NA = Medicare has not developed a rate for the In-Office or ASC setting as the procedure is typically performed in the hospital setting. For physicians,if the contractor determines the service can be performed in-office, the procedure will be paid at the MD In-facility rate.1 Source: Beebe et al . (2008). CPT ® 2009 Professional Edition . Chicago: American Medical Association. CPT® is a registered trademark of American Medical Association. All Rights Reserved.2 Source: November 19, 2008 Federal Register. MD payments calculated using the 2009 conversion factor of $36.066.3 Source: November 18, 2008 Federal Register.4 National average (wage index greater than one) MS-DRG rates calculated using the national adjusted full update standardized labor, non-labor and capital amounts ($5552.58). Source: October 3, 2008 Federal Register.5 The patient’s medical record must support the existence and treatment of the complication or comorbidity.6 Source: The Educational Annotation of ICD-9-CM, Reno, NV; Channel Publishing Ltd. Copyright 2006. Craig D. Puckett, Fifth Edition. 9See important information about the uses and limitations of this document on page 1.
  • 10. PROCEDURAL REIMBURSEMENT GUIDESelect Endoscopy Procedures Physician 2 FacilityInpatient Information effective through 9/30/2009. 3 4All other information effective through 12/31/2009. Outpatient Inpatient 2009 Medicare 2009 Medicare 2009 Medicare 2009 National National National Medicare Possible MS-DRG Average Average Average National Assignments and 2009 Physician Physician Hospital Average Medicare National CPT® Payment In- Payment In- Outpatient ASC Facility Possible ICD-9-CM Average Inpatient 1 6 Code Code Description office Facility Payment Payment Procedural Codes PaymentERCP + CholangioscopyDiagnostic 51.1: 435: Malignancy of ERCP; diagnostic, with or without collection of specimen(s) Endoscopic retrograde hepatobiliary system or43260 + by brushing or washing (separate procedure) + NA* $461 $2,173 $990 cholangiopancreato-graphy pancreas with Major43723 Cholangioscopy (ERCP) Complication or Comorbidity (MCC5)Therapeutic $9,55343261+ ERCP; with biopsy, single or multiple + Cholangioscopy NA* $479 $2,173 $990 436:43273 51.11: Malignancy of hepatobiliary system or43262 + Endoscopic retrograde ERCP; with sphincterotomy/papillotomy + Cholangioscopy NA* $540 $2,173 $990 pancreas with43273 cholangiography (ERC) Complication or 5 Comorbidity (CC )43263 + ERCP; with pressure measurement of sphincter of Oddi $6,619 NA* $536 $2,173 $99043273 (pancreatic duct or common bile duct) + Cholangioscopy 51.14: 437: Malignancy of ERCP; with endoscopic retrograde removal of Other closed (endoscopic) hepatobiliary system or43264 + biopsy of biliary duct or pancreas without calculus/calculi from biliary and/or pancreatic ducts NA* $624 $2,173 $99043273 7 sphincter of Oddi CC/MCC +Cholangioscopy $5,292 441: Disorders of liver except malignancy, cirrhosis,43265 + ERCP; endoscopic retrograde destruction, lithotripsy of NA* $685 $2,173 $990 alcoholic hepatitis with43273 calculus/calculi, any method+ Cholangioscopy MCC $9,239 442: Disorders of liver except malignancy, cirrhosis,43267 + ERCP; endoscopic retrograde insertion of nasobiliary or alcoholic hepatitis with NA* $539 $2,173 $99043273 nasopancreatic drainage tube + Cholangioscopy CC $5,458 443: Disorders of liver except malignancy,43271 + ERCP; endoscopic retrograde balloon dilation of ampulla, cirrhosis, alcoholic NA* $540 $2,173 $99043273 biliary and/or pancreatic duct(s)+ Cholangioscopy 7 hepatitis without CC/MCC $3,877 ERCP; with ablation of tumor(s), polyp(s), or other lesion(s) 444:43272 + not amenable to removal by hot biopsy forceps, bipolar NA* $539 $2,173 $990 Disorders of the biliary43273 cautery or snare technique+ Cholangioscopy tract with MCCStenting $8,65343268 + ERCP; with endoscopic retrograde insertion of tube or stent 7 NA* $546 $2,422 $1,066 445:43273 into bile or pancreatic duct + Cholangioscopy43269 + ERCP; with endoscopic retrograde removal of foreign body Disorders of the biliary NA* $586 $2,422 $1,06643273 and/or change of tube or stent + Cholangioscopy tract with CCFluoroscopy $5,769 Endoscopic catheterization of the biliary ductal system, No additional No additional 74328 $0 NA* radiological supervision and interpretation. payment*** payment*** 446: Endoscopic catheterization of the pancreatic ductal system, No additional No additional Disorders of the biliary 74329 $0 NA* radiological supervision and interpretation. payment*** payment*** tract without CC/MCC Combined endoscopic catheterization of the biliary and $4,015 No additional No additional 74330 pancreatic ductal systems, radiological supervision and $0 NA* payment*** payment*** interpretation.* NA = Medicare has not developed a rate for the In-Office or ASC setting as the procedure is typically performed in the hospital setting. For physicians,if the contractor determines the service can be performed in-office, the procedurewill be paid at the MD In-facility rate.1Source: Beebe et al. (2008). CPT ® 2009 Professional Edition. Chicago: American Medical Association. CPT® is a registered trademark of American Medical Association. All Rights Reserved.2Source: November 19, 2008 Federal Register. MD payments calculated using the 2009 conversion factor of $36.066.3Source: November 18, 2008 Federal Register.4National average (wage index greater than one) MS-DRG rates calculated using the national adjusted full update standardized labor, non-labor and capital amounts ($5552.58). Source: October 3, 2008 Federal Register.5The patient’s medical record must support the existence and treatment of the complication or comorbidity.6Source: The Educational Annotation of ICD-9-CM, Reno, NV; Channel Publishing Ltd. Copyright 2006. Craig D. Puckett, Fifth Edition.7SpyGlass® Direct Visualization System is not FDA-cleared for use in the pancreatic ducts.Boston Scientific does not have a SpyGlass® Direct Visualization System device that is FDA-cleared for use in the pancreatic ductsSee important information about the uses and limitations of this document on page 1. 10
  • 11. Endoscopy C-code SummaryEncourage your customers to add the following C-codes to their chargemasters:C-code C-code Description Relevant Boston Scientific Devices1C1726 Catheter, balloon dilation, non-vascular CRE™ single-use fixed wire balloon dilators CRE™ single-use pulmonary balloon dilators CRE™ single-use wire-guided esophageal/pyloric balloon dilators CRE™ single-use wire-guided esophageal/pyloric/colonic balloon dilators Hurricane® RX single-use biliary balloon dilatation catheters MaxForce™ single-use biliary dilatation balloon MaxForce™ single-use esophageal balloon dilators MaxForce™ TTS single-use balloon dilators Passage™ single-use biliary dilatation catheters Rigiflex® II single-use achalasia balloon dilatorsC1769 Guide wire All BSC guide wires used in GI procedures Hydratome® RX cannulating sphincterotomes Jagtome® RX cannulating sphincterotomesC1874 Stent, coated/covered, with delivery system Polyflex® single-use esophageal stent system Polyflex® single-use self-expanding silicone airway stent system Ultraflex™ single-use covered esophageal NG stent system – proximal release Ultraflex™ single-use covered large esophageal NG stent system – proximal release Ultraflex™ single-use covered large esophageal NG stent system – distal release Ultraflex™ single-use covered tracheobronchial stent system – distal release WALLSTENT® RX single-use biliary endoprosthesis with Permalume® covering WALLSTENT® single-use esophageal II endoprosthesis with Permalume® covering and Unistep™ Plus delivery system WALLSTENT® single-use tracheobronchial endoprosthesis with Permalume® covering and Unistep® Plus delivery system WALLFLEX ® partially covered esophageal stentC1875 Stent, coated/covered without delivery system DYNAMICTM (Y) StentC1876 Stent, non-coated/non-covered, with delivery Ultraflex™ Diamond™ single-use biliary stent system system Ultraflex™ Precision single-use colonic stent system Ultraflex™ single-use noncovered esophageal NG stent system – distal release Ultraflex™ single-use noncovered esophageal NG stent system – proximal release Ultraflex™ single-use noncovered tracheobronchial stent system – distal release Ultraflex™ single-use noncovered tracheobronchial stent system – proximal release WALLSTENT ® RX single-use biliary endoprosthesis WALLSTENT ® single-use biliary endoprosthesis WALLSTENT ® single-use colonic and duodenal endoprosthesis with Unistep® Plus delivery system WALLFLEX ® single-use colonic stent system WALLFLEX ® single-use duodenal stent systemC2617 Stent, non-coronary, temporary, without C-Flex® single-use pigtail biliary stent delivery system Percuflex® Amsterdam single-use biliary stent without introducer kitC2625 Stent, non-coronary, temporary, with delivery Flexima® single-use biliary stent system system Percuflex® Amsterdam single-use biliary stent with introducer kits1 RX single-use plastic biliary stents1 For devices packaged in kits, hospitals may bill for the components of the kits that individually qualify under the new category pass-through C-codes.Facilities should bill for the estimated proportion of the kit that the C-code eligible device comprises.See important information about the uses and limitations of this document on page 1. 11
  • 12. Boston Scientific Corporation One Boston Scientific Place Natick, MA 01760-1537 www.bostonscientific.com ©2008 Boston Scientific Corporation or its affiliates. All rights reserved. MVG14010 12/08 Expires 12/31/09See important information about the uses and limitations of this document on page 1.