Coding Guidance for Common ASC Specialties Understand the rules behind the codes BY MANDEARA FRYE

Successful coding requires ASC coders to under- stand the rules concern- ing their ASCs’ specialties and the procedures within

those specialties. Individual specialties and procedures have their own unique coding rules. Let us examine some of the quirk- ier and more confusing coding rules associated with common ASC special- ties: gastroenterology, ophthalmology, orthopedics and pain management.


When coding esophageal dilations, read the operative report to determine the type of esophageal dilation per- formed. Some common CPT choices include the following: ■

43248—Esophagogastroduodenos- copy (EGD) with insertion of guide- wire followed by passage of dilator through esophagus over guide wire

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43249—EGD with balloon dilation less than 30 mm diameter

43233—EGD with balloon dilation 30 mm diameter or larger

43450—Dilation of esophagus by unguided sound or bougie (may or may not be done in the same setting as an EGD, which is sepa- rately reportable)

43453—Dilation of esophagus over guide wire For endoscopic mucosal resections, understand the documentation require- ments for accurate reporting. According to AMA CPT Assistant January 2017, to report 45390, documentation must support a submucosal injection to lift the lesion, demarcation of the lesion and endoscopic snare resection. If the demarcation is missing from the doc-

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umentation, review other code options for the method of removal and the injection. For example, if documenta- tion supports a snare removal as well as the injection, then report 45385 for the snare removal and 45381 for the injec- tion pending documentation. Finally, there remains confusion

about what is considered a screen- ing versus diagnostic colonoscopy. A few tips: If a symptom is documented, the procedure is no longer considered a screening. If the indication for the procedure is listed as “personal his- tory of polyps,” this may constitute a screening, according to AHA Coding Clinic (1st Quarter, 2017). If a patient scheduled for a screening is not due for one, according to US Preventive Ser- vices Task Force recommendations, review the history and physical (H&P) or query the surgeon to see if you should use another indication. Watch for symptoms to be documented in conjunction with screening, since the symptoms take precedence, and edu- cate providers on coding rules.

Ophthalmology If your ASC performs complex cat- aracts, learn your state’s local cov-

erage determination (LCD) criteria for these procedures, including spe- cific diagnoses that may be required. While the American Medical Asso- ciation (AMA) does not consider the use of trypan blue as complex, several Medicare administrative contractors do. The March 2016 CPT Assistant outlines criteria for complex cata- racts. It specifies that installing and removing trypan blue from the ante- rior chamber does not justify a com- plex cataract (66982). The additional work that does meet the requirement includes: ■

A miotic pupil that does not dilate sufficiently and requires insertion of one of the following: four iris retrac- tors through four additional inci- sions; a Beehler expansion device; a sector iridectomy with subse- quent suture repair of an iris sphinc- ter; or sphincterotomies created with scissors.

A disease state that causes lens sup- port structures to be weakened or absent and requires the lens implant to be supported with permanent intraocular sutures or a capsular tension ring to allow placement of an intraocular lens.

The advice and opinions expressed in this column are those of the author and do not represent official Ambulatory Surgery Center Association policy or opinion.

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