Post on 18-Apr-2018
2015 Procedural Reimbursement Guide for Endoscopy
THIS PROCEDURAL REIMBURSEMENT GUIDE, FOR SELECT ENDOSCOPY PROCEDURES, provides coding and reimbursement information for physicians and facilities. The Medicare payment amounts shown are national average payments. Actual reimbursement will vary for each provider and institution based on geographic differences in costs, hospital teaching status, and proportion of low-income patients.
DESCRIPTION OF PAYMENT METHODS
PHYSICIAN BILLING AND PAYMENT: Medicare and most other insurers typically reimburse physicians based on fee schedules tied to CPT® CODES. CPT Codes are published by the American Medical Association and are used to report medical services and procedures performed by or under the direction of physicians.
HOSPITAL OUTPATIENT BILLING AND PAYMENT: Medicare reimburses hospitals for outpatient stays (typically stays of less than 24 hours) under AMBULATORY PAYMENT CLASSIFICATION GROUPS (APCs). Medicare assigns a procedure to an APC based on the billed CPT Code. Hospitals may receive separate APC payments for each procedure done during the same outpatient visit. Many APCs are subject to reduced payment when multiple procedures are performed on the same day. In most cases, the highest valued procedure is paid at 100% and all other procedures are subject to a 50% payment reduction.
HOSPITAL INPATIENT BILLING AND PAYMENT: Medicare reimburses hospital inpatient procedures based on the MEDICARE SEVERITY DIAGNOSIS RELATED GROUP (MS-DRG). The MS-DRG is a system of classifying patients based on their diagnoses and the procedures performed during their hospital stay. MS DRGs closely calibrate payment to the severity of a patient’s illness. One single MS-DRG payment is intended to cover all hospital costs associated with treating an individual during his or her hospital stay, with the exception of “professional” (e.g., physician charges associated with performing medical procedures). Private payers may also use MS-DRG based systems or other payer-specific system to pay hospitals for providing inpatient services. Effective October 1, 2013, Medicare implemented two-midnight stay guidance. Inpatient admittance is presumed to be appropriate if a physician expects a beneficiary’s surgical procedure, diagnostic test or other treatment to require a stay in the hospital lasting at least two midnights, and admits the beneficiary to the hospital based on that expectation. Documentation in the medical record must support a reasonable expectation of the need for the beneficiary to require a medically necessary stay lasting at least two midnights. If the inpatient admission lasts fewer than two midnights due to an unforeseen circumstance this also must be clearly documented in the medical record.
FREE-STANDING CLINIC/AMBULATORY SURGICAL CENTER BILLING AND PAYMENT: Many procedures are performed outside of the hospital in free-standing clinics. Payments made to free-standing clinics from private insurers depend on the contract the clinic has with the payer. Medicare payments to free-standing clinics are determined in part, by the licensing status of the clinic. If a free-standing clinic is licensed by Medicare as an AMBULATORY SURGICAL CENTER (ASC) it is eligible to be reimbursed for select procedures provided in this setting. Not all procedures that Medicare covers in the hospital setting are eligible for payment in ASCs. Medicare has approved over 3,000 procedures (as defined by CPT Code), for which it will pay the ASC a facility fee.
Effective: 1-JAN-2015
Expires: 31-DEC-2015
ENDO-47410-AF DEC2014 2
CPT copyright 2014 American Medical Association.
All rights reserved. CPT is a registered trademark of
the American Medical Association.
THIS GUIDE, FOR SELECT ENDOSCOPY PROCEDURES, PROVIDES CODING AND REIMBURSEMENT INFORMATION FOR PHYSICIANS AND FACILITIES.
THE CODES INCLUDED IN THIS GUIDE ARE INTENDED TO REPRESENT TYPICAL ENDOSCOPY PROCEDURES WHERE THERE IS:
1) At least one device approved or cleared 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 medical devices.
THE MEDICARE REIMBURSEMENT AMOUNTS SHOWN ARE CURRENTLY PUBLISHED NATIONAL AVERAGE PAYMENTS.
Actual reimbursement will vary for each provider and institution for a variety of reasons including geographic difference in labor and non-labor costs, hospital teaching status, and/or proportion of low-income patients. On average, private payers pay significantly more than Medicare.8
Please feel free to contact the Boston Scientific reimbursement department if you have any questions.
Rates referenced in this guide do not reflect Sequestration; automatic reductions in federal spending that will result in a 2% across-the-board reduction to ALL Medicare rates as of January 1, 2015.
You can find reimbursement updates on our website: WWW.BOSTONSCIENTIFIC.COM/REIMBURSEMENT
Health economic and reimbursement information provided by Boston Scientific Corporation is gathered from third-party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules and policies. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice. Boston Scientific encourages providers to submit accurate and appropriate claims for services. It is always the provider’s responsibility to determine medical necessity, the proper site for delivery of any services and to submit appropriate codes, charges, and modifies for services that are rendered. Boston Scientific recommends that you consults with your payers, reimbursements specialists and/or legal counsel regarding coding, coverage and reimbursement matters. Boston Scientific does not promote the use of its products outside their FDA-approved label.
Effective: 1-JAN-2015
Expires: 31-DEC-2015
ENDO-47410-AF DEC2014 3
Medicare Physician, Hospital Outpatient, and ASC Payments
Hospital Inpatient Coding Hospital Inpatient Medicare Payment
CPT® Code1 Code Description Work Total Office Total
Facility In-Office In-Facility Hospital Outpatient ASC
Diagnostic
43260 Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
5.95 9.82 9.82 $351 $351 $1,952 $1,071
Therapeutic
43261 Endoscopic retrograde cholangiopancreatography (ERCP); with biopsy, single or multiple
6.25 10.28 10.28 $368 $368 $1,952 $1,071
43262 Endoscopic retrograde cholangiopancreatography (ERCP); with sphincterotomy/papillotomy
6.60 10.85 10.85 $388 $388 $1,952 $1,071
43263 Endoscopic retrograde cholangiopancreatography (ERCP); with pressure measurement of sphincter of Oddi
6.60 10.88 10.88 $389 $389 $1,952 $1,071
43264 Endoscopic retrograde cholangiopancreatography (ERCP); with removal of calculi/debris from biliary/pancreatic duct(s)
6.73 11.06 11.06 $395 $395 $1,952 $1,071
43265 Endoscopic retrograde cholangiopancreatography (ERCP); with destruction of calculi, any method (eg, mechanical, electrohydraulic, lithotripsy)
8.03 13.12 13.12 $469 $469 $1,952 $1,071
43277 Endoscopic retrograde cholangiopancreatography (ERCP); with trans-endoscopic balloon dilation of biliary/pancreatic duct(s) or of ampulla (sphincteroplasty), including sphincterotomy, when performed, each duct
7.00 11.48 11.48 $410 $410 $1,952 $1,071
43278 Endoscopic retrograde cholangiopancreatography (ERCP); with ablation of tumor(s), polyp(s), or other lesion(s), including pre- and post-dilation and guide wire passage, when performed
8.02 13.11 13.11 $469 $469 $1,952 $1,071
Stenting
43274 Endoscopic retrograde cholangiopancreatography (ERCP); with placement of endoscopic stent into biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent
8.58 14.00 14.00 $501 $501 $3,174 $1,313
43275 Endoscopic retrograde cholangiopancreatography (ERCP); with removal of foreign body(s) or stent(s) from biliary/pancreatic duct(s)
6.96 11.42 11.42 $408 $408 $1,952 $1,071
43276 Endoscopic retrograde cholangiopancreatography (ERCP); with removal and exchange of stent(s), biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent exchanged
8.94 14.57 14.57 $521 $521 $3,174 $1,313
Possible ICD-9-CM Procedure Codes
Code Description
51.10 Endoscopic retrograde cholangiopancreatography (ERCP)
51.11 Endoscopic retrograde cholangiography (ERC)
51.14 Other closed (endoscopic) biopsy of biliary duct or sphincter of Oddi
MS-DRG Description
Hospital Inpatient Medicare National Average Payment4
435 Malignancy of hepatobiliary system or pancreas with Major Complication or Comorbidity (MCC5)
$10,279
436 Malignancy of hepatobiliary system or pancreas with Complication or Comorbidity (CC5) $6,827
437 Malignancy of hepatobiliary system or pancreas without CC/MCC $5,262
438 Disorders of pancreas except malignancy with MCC5 $9,985
439 Disorders of pancreas except malignancy with CC5 $5,320
440 Disorders of pancreas except malignancy without CC/MCC $3,768
441 Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis with MCC5 $11,048
442 Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis with CC5 $5,435
443 Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis without CC/MCC $3,820
444 Disorders of the biliary tract with MCC5 $9,509
445 Disorders of the biliary tract with CC5 $6,249
446 Disorders of the biliary tract without CC/MCC $4,439
ENDO-47410-AF DEC2014Please refer to page 17 for footnotesSee important information about the uses and limitations of this document on pages 2 and 3 4
Biliary Procedural Reimbursement Guide - Select Endoscopy Procedures
RVUs Physician‡,2 Facility3
2015 Medicare National Average Payment
Medicare Physician, Hospital Outpatient, and ASC Payments
CPT® Code1 Code Description Work Total Office Total
Facility In-Office In-Facility Hospital Outpatient ASC
Cold Biopsy
43202 Esophagoscopy, flexible, transoral; with biopsy, single or multiple 1.82 10.40 3.23 $372 $115 $745 $409
43193 Esophagoscopy, rigid, transoral; with biopsy, single or multiple 2.79 4.93 4.93 $176 $176 $1,064 $584
43239 Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple
2.49 11.48 4.29 $410 $153 $745 $409
43261 Endoscopic retrograde cholangiopancreatography (ERCP); with biopsy, single or multiple
6.25 10.28 10.28 $368 $368 $1,952 $1,071
44361 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with biopsy, single or multiple
2.87 4.91 4.91 $176 $176 $852 $467
44377 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with biopsy, single or multiple
5.52 9.13 9.13 $326 $326 $1,249 $685
44382 Ileoscopy, through stoma; with biopsy, single or multiple 1.27 2.33 2.33 $83 $83 $852 $467
44386 Endoscopic evaluation of small intestinal pouch (eg, Kock pouch, ileal reservoir [S or J]); with biopsy, single or multiple
2.12 10.10 3.66 $361 $131 $790 $433
44389 Colonoscopy through stoma; with biopsy, single or multiple 3.13 11.27 5.30 $403 $189 $790 $433
45305 Proctosigmoidoscopy, rigid; with biopsy, single or multiple 1.25 5.58 2.29 $200 $82 $827 $454
45331 Sigmoidoscopy, flexible; with biopsy, single or multiple 1.15 4.64 2.16 $166 $77 $494 $271
45380 Colonoscopy, flexible; with biopsy, single or multiple 4.43 13.18 7.40 $471 $265 $790 $433
Hot Biopsy
43216 Esophagoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
2.40 12.04 4.18 $430 $149 $1,914 $1,050
43250 Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
3.07 13.13 5.22 $469 $187 $1,064 $584
44365 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery
3.31 5.46 5.46 $195 $195 $1,249 $685
44392 Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
3.81 12.52 6.28 $448 $225 $790 $433
45308 Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery
1.40 6.28 2.59 $225 $93 $827 $454
45333 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
1.79 8.46 3.17 $302 $113 $494 $271
45384 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
4.69 13.21 7.76 $472 $277 $790 $433
ENDO-47410-AF DEC2014Please refer to page 17 for footnotesSee important information about the uses and limitations of this document on pages 2 and 3
Hospital Inpatient Coding and Medicare PaymentInpatient payment information not shown because the biopsy procedure will rarely, if ever, be the primary reason for a hospital admission.
5
Biopsy Procedural Reimbursement Guide - Select Endoscopy Procedures
RVUs Physician‡,2 Facility3
2015 Medicare National Average Payment
Medicare Physician, Hospital Outpatient, and ASC Payments
Hospital Inpatient Coding and Medicare Payment
CPT® Code1 Code Description Work Total Office Total
Facility In-Office In-Facility Hospital Outpatient ASC
Balloon
43195 Esophagoscopy, rigid, transoral; with balloon dilation (less than 30 mm diameter)
3.07 5.39 5.39 $193 $193 $1,064 $584
43214 Esophagoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed)
3.50 5.86 5.86 $210 $210 $1,064 $584
43220 Esophagoscopy, flexible, transoral; with transendoscopic balloon dilation (less than 30 mm diameter)
2.10 32.49 3.67 $1,162 $131 $1,064 $584
43233 Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed)
4.17 6.91 6.91 $247 $247 $1,064 $584
43249 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter)
2.77 31.03 4.75 $1,109 $170 $1,064 $584
44381 Ileoscopy, through stoma; with transendoscopic balloon dilation Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
$852 $467
45340 Sigmoidoscopy, flexible; with transendoscopic balloon dilation 1.89 13.86 3.33 $496 $119 $827 $45445386 Colonoscopy, flexible; with transendoscopic balloon dilation 4.57 18.96 7.60 $678 $272 $790 $43344405 Colonoscopy through stoma; with transendoscopic balloon dilation Facility Only
for 2015 Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
$790 $433
Balloon or Rigid
43196 Esophagoscopy, rigid, transoral; with insertion of guide wire followed by dilation over guide wire
3.31 5.71 5.71 $204 $204 $1,064 $584
43213 Esophagoscopy, flexible, transoral; with dilation of esophagus, by balloon or dilator, retrograde (includes fluoroscopic guidance, when performed)
4.73 35.34 7.85 $1,264 $281 $1,064 $584
43226 Esophagoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) over guide wire
2.34 10.91 4.04 $390 $144 $1,064 $584
43245 Esophagogastroduodenoscopy, flexible, transoral; with dilation of gastric/duodenal stricture(s) (eg, balloon, bougie)
3.18 17.69 5.39 $633 $193 $1,064 $584
43248 Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire
3.01 11.83 5.14 $423 $184 $745 $409
45303 Proctosigmoidoscopy, rigid; with dilation (eg, balloon, guide wire, bougie) 1.50 27.58 2.69 $986 $96 $827 $454
ENDO-47410-AF DEC2014Please refer to page 17 for footnotesSee important information about the uses and limitations of this document on pages 2 and 3
Inpatient payment information not shown because the dilation procedure will rarely, if ever, be the primary reason for a hospital admission.
6
Dilation Procedural Reimbursement Guide - Select Endoscopy Procedures
RVUs Physician‡,2 Facility3
2015 Medicare National Average Payment
Medicare Physician, Hospital Outpatient, and ASC Payments
CPT® Code1 Code Description Work Total Office Total
Facility In-Office In-Facility Hospital Outpatient ASC
Gastrostomy Tube Initial Placement
43246 Esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube
3.66 6.11 6.11 $218 $218 $1,064 $584
49440 Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report
4.18 29.60 6.48 $1,058 $232 $1,064 $584
Gastrostomy Tube Replacement/Reposition
43760 Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance
0.90 13.98 1.38 $500 $49 $195 $107
49450 Replacement of gastrostomy or cecostomy (or other colonic) tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report
1.36 18.97 1.96 $678 $70 $488 $268
43761 Repositioning of a naso- or oro-gastric feeding tube, through the duodenum for enteric nutrition
2.01 3.36 2.99 $120 $107 $745 $409
Jejunostomy Tube
49452 Replacement of gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report
2.86 25.60 4.10 $915 $147 $488 $268
49446 Conversion of gastrostomy tube to gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report
3.31 28.45 4.75 $1,017 $170 $1,064 $584
44373 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with conversion of percutaneous gastrostomy tube to percutaneous jejunostomy tube
3.49 5.88 5.88 $210 $210 $1,249 $685
49440 Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report
4.18 29.60 6.48 $1,058 $232 $1,064 $584
Other Procedures
49460 Mechanical removal of obstructive material from gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, any method, under fluoroscopic guidance including contrast injection(s), if performed, image documentation and report
0.96 20.85 1.40 $745 $50 $488 $268
ENDO-47410-AF DEC2014Please refer to page 17 for footnotesSee important information about the uses and limitations of this document on pages 2 and 3
Hospital Inpatient Coding and Medicare PaymentInpatient payment information not shown because the enteral feeding procedure will rarely, if ever, be the primary reason for a hospital admission.
7
Enteral Feeding Procedural Reimbursement Guide Select Endoscopy Procedures
RVUs Physician‡,2 Facility3
2015 Medicare National Average Payment
Medicare Physician, Hospital Outpatient, and ASC Payments
Hospital Inpatient Coding and Medicare Payment
CPT® Code1 Code Description Work Total
OfficeTotal
Facility In-Office In-Facility Hospital Outpatient ASC
Control of Bleeding
43227 Esophagoscopy, flexible, transoral; with control of bleeding, any method 2.99 11.33 5.09 $405 $182 $1,064 $584
43255 Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method
3.66 12.40 6.17 $443 $221 $1,064 $584
44366 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)6
4.40 7.36 7.36 $263 $263 $1,249 $685
44378 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)6
7.12 11.68 11.68 $418 $418 $1,249 $685
44391 Colonoscopy through stoma; with control of bleeding, any method 4.31 14.20 7.20 $508 $257 $790 $433
45334 Sigmoidoscopy, flexible; with control of bleeding, any method 2.73 4.68 4.68 $167 $167 $827 $454
45382 Colonoscopy, flexible; with control of bleeding, any method 5.68 17.12 9.39 $612 $336 $790 $433
Ligation
43205 Esophagoscopy, flexible, transoral; with band ligation of esophageal varices 2.54 4.35 4.35 $156 $156 $1,064 $584
43244 Esophagogastroduodenoscopy, flexible, transoral; with band ligation of esophageal/gastric varices
4.50 7.52 7.52 $269 $269 $1,064 $584
46221 Hemorrhoidectomy, internal, by rubber band ligation(s) 2.36 7.73 5.53 $276 $198 $442 $179
45350 Sigmoidoscopy, flexible; with band ligation(s) (eg, hemorrhoids) Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
$827 $454
45398 Colonoscopy, flexible; with band ligation(s) (eg, hemorrhoids) Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
$790 $433
Injection
43201 Esophagoscopy, flexible, transoral; with directed submucosal injection(s), any substance
1.82 7.92 3.22 $283 $115 $1,064 $584
43192 Esophagoscopy, rigid, transoral; with directed submucosal injection(s), any substance
2.79 4.94 4.94 $177 $177 $1,064 $584
43204 Esophagoscopy, flexible, transoral; with injection sclerosis of esophageal varices
2.43 4.22 4.22 $151 $151 $745 $409
43236 Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance
2.49 11.20 4.30 $400 $154 $745 $409
43243 Esophagogastroduodenoscopy, flexible, transoral; with injection sclerosis of esophageal/gastric varices
4.37 7.25 7.25 $259 $259 $745 $409
45335 Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance 1.46 7.83 2.65 $280 $95 $494 $271
44404 Colonoscopy through stoma; with directed submucosal injection(s), any substance
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
$790 $433
45381 Colonoscopy, flexible; with directed submucosal injection(s), any substance 4.19 13.24 7.01 $473 $251 $790 $433
MS-DRG Description
Hospital Inpatient Medicare National Average Payment4
377 GI Hemorrhage with Major Complication or Comorbidity (MCC5) $10,426
378 GI Hemorrhage with Complication or Comorbidity (CC5) $5,878
379 GI Hemorrhage without CC/MCC $3,975
432 Cirrhosis & alcoholic hepatitis with MCC5 $9,801
433 Cirrhosis & alcoholic hepatitis with CC5 $5,381
434 Cirrhosis & alcoholic hepatitis without CC/MCC $3,654
ENDO-47410-AF DEC2014Please refer to page 17 for footnotesSee important information about the uses and limitations of this document on pages 2 and 3 8
Hemostasis Procedural Reimbursement Guide - Select Endoscopy Procedures
RVUs Physician‡,2 Facility3
2015 Medicare National Average Payment
Medicare Physician, Hospital Outpatient, and ASC Payments
Hospital Inpatient Coding and Medicare Payment
CPT® Code1 Code Description Work Total Office Total
Facility In-Office In-Facility Hospital Outpatient ASC
Hot Biopsy
43216 Esophagoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
2.40 12.04 4.18 $430 $149 $1,914 $1,050
43250 Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
3.07 13.13 5.22 $469 $187 $1,064 $584
44365 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery
3.31 5.46 5.46 $195 $195 $1,249 $685
44392 Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
3.81 12.52 6.28 $448 $225 $790 $433
45308 Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery
1.40 6.28 2.59 $225 $93 $827 $454
45333 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
1.79 8.46 3.17 $302 $113 $494 $271
45384 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
4.69 13.21 7.76 $472 $277 $790 $433
Snare
43217 Esophagoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
2.90 12.83 4.94 $459 $177 $1,064 $584
43251 Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
3.57 14.42 6.02 $516 $215 $1,064 $584
44364 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
3.73 6.27 6.27 $224 $224 $1,249 $685
44394 Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
4.42 14.15 7.35 $506 $263 $790 $433
45309 Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by snare technique
1.50 6.32 2.61 $226 $93 $827 $454
45338 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
2.34 9.08 4.04 $325 $144 $827 $454
45385 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
5.30 14.88 8.78 $532 $314 $790 $433
Hot Biopsy or Snare
45315 Proctosigmoidoscopy, rigid; with removal of multiple tumors, polyps, or other lesions by hot biopsy forceps, bipolar cautery or snare technique
1.80 7.10 3.25 $254 $116 $827 $454
Other
43229 Esophagoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)
3.59 20.88 6.06 $747 $217 $1,914 $1,050
Foreign Body Removal
43215 Esophagoscopy, flexible, transoral; with removal of foreign body(s) 2.54 11.73 4.36 $419 $156 $1,064 $584
43247 Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body(s)
3.21 11.71 5.45 $419 $195 $745 $409
44363 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of foreign body(s)
3.49 5.88 5.88 $210 $210 $852 $467
45307 Proctosigmoidoscopy, rigid; with removal of foreign body 1.70 6.39 2.97 $228 $106 $1,657 $909
45332 Sigmoidoscopy, flexible; with removal of foreign body(s) 1.79 8.32 3.18 $297 $114 $827 $454
45379 Colonoscopy, flexible; with removal of foreign body(s) 4.68 14.25 7.78 $510 $278 $790 $433
43194 Esophagoscopy, rigid, transoral; with removal of foreign body(s) 3.51 5.56 5.56 $199 $199 $1,064 $584
Endoscopic Mucosal Resection
43211 Esophagoscopy, flexible, transoral; with endoscopic mucosal resection 4.30 7.27 7.27 $260 $260 $1,064 $584
43254 Esophagogastroduodenoscopy, flexible, transoral; with endoscopic mucosal resection
4.97 8.25 8.25 $295 $295 $1,064 $584
44403 Colonoscopy through stoma; with endoscopic mucosal resection Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
$790 $433
45349 Sigmoidoscopy, flexible; with endoscopic mucosal resection Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
$827 $454
45390 Colonoscopy, flexible; with endoscopic mucosal resection Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
$790 $433
ENDO-47410-AF DEC2014Please refer to page 17 for footnotesSee important information about the uses and limitations of this document on pages 2 and 3
Inpatient payment information not shown because the polypectomy procedure will rarely, if ever, be the primary reason for a hospital admission.
9
Polypectomy Procedural Reimbursement Guide - Select Endoscopy Procedures
RVUs Physician‡,2 Facility3
2015 Medicare National Average Payment
Medicare Physician, Hospital Outpatient, and ASC Payments
CPT® Code1 Code Description Work Total Office Total
Facility In-Office In-Facility Hospital Outpatient ASC
Biopsy
31625 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial or endobronchial biopsy(s), single or multiple sites
3.36 9.49 4.92 $339 $176 $1,055 $578
31628 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial lung biopsy(s), single lobe
3.80 10.60 5.48 $379 $196 $1,055 $578
31632 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial lung biopsy(s), each additional lobe (List separately in addition to code for primary procedure)*
1.03 2.03 1.41 $73 $50 $0 $0
Cytology and Brush
31622 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed (separate procedure)
2.78 8.92 4.20 $319 $150 $1,055 $578
31623 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with brushing or protected brushings
2.88 9.43 4.23 $337 $151 $1,055 $578
31624 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial alveolar lavage
2.88 8.93 4.27 $319 $153 $1,055 $578
Foreign Body Removal (Stent Removal)
31635 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with removal of foreign body
3.67 9.97 5.45 $356 $195 $1,055 $578
Needle Aspiration
31629 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i)
4.09 16.78 5.91 $600 $211 $2,255 $1,237
31633 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), each additional lobe (List separately in addition to code for primary procedure)*
1.32 2.51 1.83 $90 $65 $0 $0
31645 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with therapeutic aspiration of tracheobronchial tree, initial (eg, drainage of lung abscess)
3.16 9.22 4.66 $330 $167 $1,055 $578
Stenting
31631 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of tracheal stent(s) (includes tracheal/bronchial dilation as required)
4.36 6.70 6.70 $240 $240 $2,255 $1,237
31636 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of bronchial stent(s) (includes tracheal/bronchial dilation as required), initial bronchus
4.30 6.41 6.41 $229 $229 $2,255 $1,237
31637 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; each additional major bronchus stented (List separately in addition to code for primary procedure)*
1.58 2.14 2.14 $77 $77 $0 $0
31638 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with revision of tracheal or bronchial stent inserted at previous session (includes tracheal/bronchial dilation as required)
4.88 7.34 7.34 $262 $262 $2,255 $1,237
Balloon Dilation
31630 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with tracheal/bronchial dilation or closed reduction of fracture
3.81 5.79 5.79 $207 $207 $2,255 $1,237
Bronchial Thermoplasty
31660 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 1 lobe
4.25 6.02 6.02 $215 $215 $2,255 N/A*
31661 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 2 or more lobes
4.50 6.30 6.30 $225 $225 $2,255 N/A*
ENDO-47410-AF DEC2014Please refer to page 17 for footnotesSee important information about the uses and limitations of this document on pages 2 and 3 10
Pulmonary Procedural Reimbursement Guide - Select Endoscopy Procedures
RVUs Physician‡,2 Facility3
2015 Medicare National Average Payment
ENDO-47410-AF DEC2014Please refer to page 17 for footnotesSee important information about the uses and limitations of this document on pages 2 and 3 11
Pulmonary Procedural Reimbursement Guide - Select Endoscopy Procedures
Hospital Inpatient Coding
Hospital Inpatient Medicare Payment
Possible ICD-9-CM Procedure Codes Code Description
32.01 Endoscopic excision or destruction of lesion or tissue of bronchus
32.27 Bronchoscopic bronchial thermoplasty, ablation of airway smooth muscle
33.23 Other bronchoscopy
33.24 Closed endoscopic biopsy of bronchus; bronchoscopy (fiber-optic) with brush biopsy of “lung”, brushing or washing for specimen collection, excision (bite) biopsy
33.27 Closed endoscopic biopsy of lung; Fiber-optic bronchoscopy with fluoroscopic guidance with biopsy, transbronchial lung biopsy
31.93 Replacement of laryngeal or tracheal stent
31.99 Other operations on trachea
98.15 Removal of intraluminal foreign body from trachea and bronchus without incision
33.91 Bronchial dilation
MS-DRG Description
Hospital Inpatient Medicare National Average Payment4
180 Respiratory neoplasms with Major Complication or Comorbidity (MCC5) $9,895
181 Respiratory neoplasms pancreas with Complication or Comorbidity (CC5) $6,793
182 Respiratory neoplasms without CC/MCC $4,744
189 Pulmonary edema & respiratory failure $7,118
193 Simple pneumonia & pleurisy with MCC5 $8,500
194 Simple pneumonia & pleurisy with CC5 $5,683
195 Simple pneumonia & pleurisy without CC/MCC $4,132
196 Interstitial lung disease with MCC5 $9,757
197 Interstitial lung disease with CC5 $6,226
198 Interstitial lung disease without CC/MCC $4,724
204 Respiratory signs & symptoms $4,130
205 Other respiratory system diagnoses with MCC5 $8,211
206 Other respiratory system diagnoses without CC/MCC $4,658
163 Major Chest Procedures with MCC5,7 $29,522
164 Major Chest Procedures with CC5 $15,256
165 Major Chest Procedures without CC/MCC $10,687
Medicare Physician, Hospital Outpatient, and ASC Payments
CPT® Code1 G-Code Code Description Work Total Office Total
Facility In-Office In-Facility Hospital Outpatient ASC
Biliary Stenting
43274 Endoscopic retrograde cholangiopancreatography (ERCP); with placement of endoscopic stent into biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent
8.58 14.00 14.00 $501 $501 $3,174 $1,313
43275 Endoscopic retrograde cholangiopancreatography (ERCP); with removal of foreign body(s) or stent(s) from biliary/pancreatic duct(s)
6.96 11.42 11.42 $408 $408 $1,952 $1,071
43276 Endoscopic retrograde cholangiopancreatography (ERCP); with removal and exchange of stent(s), biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent exchanged
8.94 14.57 14.57 $521 $521 $3,174 $1,313
Esophageal Stenting
43212 Esophagoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)
3.50 5.79 5.79 $207 $207 $3,174 $1,313
43266 Esophagogastroduodenoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)
4.17 6.92 6.92 $247 $247 $3,174 $1,313
Colonic and Duodenal Stenting
43266 Esophagogastroduodenoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)
4.17 6.92 6.92 $247 $247 $3,174 $1,313
44370 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with transendoscopic stent placement (includes predilation)
4.79 8.14 8.14 $291 $291 $3,174 $1,313
44379 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with transendoscopic stent placement (includes predilation)
7.46 12.44 12.44 $445 $445 $3,174 $1,313
44384 Ileoscopy, through stoma; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
$852 $467
G6018 Ileoscopy,through stoma;with transendoscopic stent placement (includes predilation)
2.94 4.54 4.54 $162 $162 Physician Only for 2015
Reporting
Physician Only for 2015
Reporting
44402 Colonoscopy through stoma; with endoscopic stent placement (including pre- and post-dilation and guide wire passage, when performed)
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
$790 $433
G6020 Colonoscopy through stoma;with transendoscopic stent placement (includes predilation)
4.70 7.48 7.48 $267 $267 Physician Only for 2015
Reporting
Physician Only for 2015
Reporting
45327 Proctosigmoidoscopy, rigid; with transendoscopic stent placement (includes predilation)
2.00 3.54 3.54 $127 $127 $3,174 $1,313
45347 Sigmoidoscopy, flexible; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
$827 $454
G6023 Sigmoidoscopy, flexible; with transenoscopic stent placement (includes predilation)
2.92 4.80 4.80 $172 $172 Physician Only for 2015
Reporting
Physician Only for 2015
Reporting
45389 Colonoscopy, flexible; with endoscopic stent placement (includes pre- and post-dilation and guide wire passage, when performed)
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
$790 $433
G6025 Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic stent placement (includes predilation)
5.90 9.52 9.52 $340 $340 Physician Only for 2015
Reporting
Physician Only for 2015
Reporting
Tracheobronchial Stenting
31631 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of tracheal stent(s) (includes tracheal/bronchial dilation as required)
4.36 6.70 6.70 $240 $240 $2,255 $1,237
31636 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of bronchial stent(s) (includes tracheal/bronchial dilation as required), initial bronchus
4.30 6.41 6.41 $229 $229 $2,255 $1,237
31637 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; each additional major bronchus stented (List separately in addition to code for primary procedure)*
1.58 2.14 2.14 $77 $77 $0 $0
ENDO-47410-AF DEC2014Please refer to page 17 for footnotesSee important information about the uses and limitations of this document on pages 2 and 3 12
Stenting Procedural Reimbursement Guide - Select Endoscopy Procedures
RVUs Physician‡,2 Facility3
2015 Medicare National Average Payment
ENDO-47410-AF DEC2014Please refer to page 17 for footnotesSee important information about the uses and limitations of this document on pages 2 and 3
Hospital Inpatient Coding
Hospital Inpatient Medicare Payment
Possible ICD-9-CM Procedure Codes Code Description
42.81 Insertion of permanent tube into esophagus
46.86 Endoscopic insertion of colonic stent(s)
51.87 Endoscopic insertion of stent (tube) into bile duct
31.93 Replacement of laryngeal or tracheal stent
33.91 Bronchial dilation
98.15 Removal of intraluminal foreign body from trachea and bronchus without incision
MS-DRG Description
Hospital Inpatient Medicare National Average Payment4
374 Digestive malignancy with Major Complication or Comorbidity (MCC5) $11,838
375 Digestive malignancy with Complication or Comorbidity (CC5) $7,290
376 Digestive malignancy without CC/MCC $5,291
388 GI obstruction with MCC5 $9,444
389 GI obstruction with CC5 $5,113
390 GI obstruction without CC/MCC $3,539
393 Other digestive system diagnoses with MCC5 $9,909
394 Other digestive system diagnoses with CC5 $5,542
395 Other digestive system diagnoses without CC/MCC $3,856
435 Malignancy of hepatobiliary system or pancreas with MCC5 $10,279
436 Malignancy of hepatobiliary system or pancreas with CC5 $6,827
437 Malignancy of hepatobiliary system or pancreas without CC/MCC $5,262
441 Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis with MCC5 $11,048
442 Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis with CC5 $5,435
443 Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis without CC/MCC $3,820
444 Disorders of the biliary tract with MCC5 $9,509
445 Disorders of the biliary tract with CC5 $6,249
446 Disorders of the biliary tract without CC/MCC $4,439
13
Medicare Physician, Hospital Outpatient, and ASC Payments
CPT® Code1 Code Description Work Total Office Total
Facility In-Office In-Facility Hospital Outpatient ASC
Foreign Body Removal (Stent Removal)
43215 Esophagoscopy, flexible, transoral; with removal of foreign body(s) 2.54 11.73 4.36 $419 $156 $1,064 $584
43194 Esophagoscopy, rigid, transoral; with removal of foreign body(s) 3.51 5.56 5.56 $199 $199 $1,064 $584
43247 Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body(s)
3.21 11.71 5.45 $419 $195 $745 $409
43275 Endoscopic retrograde cholangiopancreatography (ERCP); with removal of foreign body(s) or stent(s) from biliary/pancreatic duct(s)
6.96 11.42 11.42 $408 $408 $1,952 $1,071
44363 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of foreign body(s)
3.49 5.88 5.88 $210 $210 $852 $467
45307 Proctosigmoidoscopy, rigid; with removal of foreign body 1.70 6.39 2.97 $228 $106 $1,657 $909
45332 Sigmoidoscopy, flexible; with removal of foreign body(s) 1.79 8.32 3.18 $297 $114 $827 $454
45379 Colonoscopy, flexible; with removal of foreign body(s) 4.68 14.25 7.78 $510 $278 $790 $433
Stenting Procedural Reimbursement Guide (Continued) Select Endoscopy Procedures
RVUs Physician‡,2 Facility3
2015 Medicare National Average Payment
Medicare Physician, Hospital Outpatient, and ASC Payments
Medicare Physician, Hospital Outpatient, and ASC Payments
CPT® Code1 Code Description Work Total Office Total
Facility In-Office In-Facility Hospital Outpatient ASC
Cholangioscopy
43273 Endoscopic cannulation of papilla with direct visualization of pancreatic/common bile duct(s) (List separately in addition to code(s) for primary procedure*
2.24 3.58 3.58 $128 $128 $0 $0
ENDO-47410-AF DEC2014Please refer to page 17 for footnotesSee important information about the uses and limitations of this document on pages 2 and 3
CPT® Code1 Code Description Work Total Office Total
Facility In-Office In-Facility Hospital Outpatient ASC
Diagnostic
43260 Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
5.95 9.82 9.82 $351 $351 $1,952 $1,071
Therapeutic
43261 Endoscopic retrograde cholangiopancreatography (ERCP); with biopsy, single or multiple
6.25 10.28 10.28 $368 $368 $1,952 $1,071
43262 Endoscopic retrograde cholangiopancreatography (ERCP); with sphincterotomy/papillotomy
6.60 10.85 10.85 $388 $388 $1,952 $1,071
43263 Endoscopic retrograde cholangiopancreatography (ERCP); with pressure measurement of sphincter of Oddi
6.60 10.88 10.88 $389 $389 $1,952 $1,071
43264 Endoscopic retrograde cholangiopancreatography (ERCP); with removal of calculi/debris from biliary/pancreatic duct(s)
6.73 11.06 11.06 $395 $395 $1,952 $1,071
43265 Endoscopic retrograde cholangiopancreatography (ERCP); with destruction of calculi, any method (eg, mechanical, electrohydraulic, lithotripsy)
8.03 13.12 13.12 $469 $469 $1,952 $1,071
43277 Endoscopic retrograde cholangiopancreatography (ERCP); with trans-endoscopic balloon dilation of biliary/pancreatic duct(s) or of ampulla (sphincteroplasty), including sphincterotomy, when performed, each duct
7.00 11.48 11.48 $410 $410 $1,952 $1,071
43278 Endoscopic retrograde cholangiopancreatography (ERCP); with ablation of tumor(s), polyp(s), or other lesion(s), including pre- and post-dilation and guide wire passage, when performed
8.02 13.11 13.11 $469 $469 $1,952 $1,071
Stenting
43274 Endoscopic retrograde cholangiopancreatography (ERCP); with placement of endoscopic stent into biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent
8.58 14.00 14.00 $501 $501 $3,174 $1,313
43275 Endoscopic retrograde cholangiopancreatography (ERCP); with removal of foreign body(s) or stent(s) from biliary/pancreatic duct(s)
6.96 11.42 11.42 $408 $408 $1,952 $1,071
43276 Endoscopic retrograde cholangiopancreatography (ERCP); with removal and exchange of stent(s), biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent exchanged
8.94 14.57 14.57 $521 $521 $3,174 $1,313
CPT Code 43273 is an add-on code and must be reported with at least one of the following ERCP codes:
14
Cholangioscopy Procedural Reimbursement Guide Select Endoscopy Procedures
RVUs
RVUs
Physician‡,2
Physician‡,2
Facility3
Facility3
2015 Medicare National Average Payment
2015 Medicare National Average Payment
ENDO-47410-AF DEC2014Please refer to page 17 for footnotesSee important information about the uses and limitations of this document on pages 2 and 3
Hospital Inpatient Coding
Hospital Inpatient Medicare Payment
Possible ICD-9-CM Procedure Codes Code Description
51.10 Endoscopic retrograde cholangiopancreatography (ERCP)
51.11 Endoscopic retrograde cholangiography (ERC)
51.14 Other closed (endoscopic) biopsy of biliary duct or sphincter of Oddi
MS-DRG Description
Hospital Inpatient Medicare National Average Payment4
435 Malignancy of hepatobiliary system or pancreas with Major Complication or Comorbidity (MCC5)
$10,279
436 Malignancy of hepatobiliary system or pancreas with Complication or Comorbidity (CC5) $6,827
437 Malignancy of hepatobiliary system or pancreas without CC/MCC $5,262
438 Disorders of the pancreas except malignancy with MCC5 $9,985
439 Disorders of the pancreas except malignancy with CC5 $5,320
440 Disorders of the pancreas except malignancy without CC/MCC $3,768
441 Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis with MCC5 $11,048
442 Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis with CC5 $5,435
443 Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis without CC/MCC $3,820
444 Disorders of the biliary tract with MCC5 $9,509
445 Disorders of the biliary tract with CC5 $6,249
446 Disorders of the biliary tract without CC/MCC $4,439
15
Cholangioscopy Procedural Reimbursement Guide Select Endoscopy Procedures
Medicare Physician, Hospital Outpatient, and ASC Payments
CPT® Code1 Code Description Work Total Office Total
Facility In-Office In-Facility Hospital Outpatient ASC
Upper Gastrointestinal Procedures
43232 Esophagoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s)
3.69 13.76 6.05 $492 $216 $1,064 $584
43238 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), (includes endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures)
4.26 7.14 7.14 $255 $255 $1,064 $584
43242 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis)
4.83 8.05 8.05 $288 $288 $1,064 $584
Lower Gastrointestinal Procedures
45342 Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s)
4.05 6.77 6.77 $242 $242 $827 $454
45392 Colonoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures
6.54 10.73 10.73 $384 $384 $790 $433
44407 Colonoscopy through stoma; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
Facility Only for 2015
Reporting
$790 $433
ENDO-47410-AF DEC2014Please refer to page 17 for footnotesSee important information about the uses and limitations of this document on pages 2 and 3
Hospital Inpatient Coding and Medicare PaymentInpatient payment information not shown because the transendoscopic ultrasound-guided fine needle aspiration procedure will rarely, if ever,
be the primary reason for a hospital admission.
16
Transendoscopic Ultrasound-Guided Fine Needle Aspiration Procedural Reimbursement Guide - Select Endoscopy Procedures
RVUs Physician‡,2 Facility3
2015 Medicare National Average Payment
ENDO-47410-AF DEC2014See important information about the uses and limitations of this document on pages 2 and 3
‡ The 2015 National Average Medicare physician payment rates have been calculated using a 2015 conversion factor of $35.7547 which reflects changes for
January 1, 2015 through March 31, 2015. Rates subject to change.
N/A* Medicare has not developed a rate for the ASC setting as the procedure is typically performed in the hospital setting.
* Add-on codes are always listed in addition to the primary procedure code.
** WallFlex™, Percuflex™ C-Flex™ and Flexima™ Biliary RX Stent Systems as well as WALLSTENT™ Biliary Endoprostheses are not FDA-cleared for use in the
pancreatic ducts.
1 CPT Copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable
FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by
the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical
services. The AMA assumes no liability for data contained or not contained herein.
2 Center for Medicare and Medicaid Services. CMS Physician Fee Schedule - January 8, 2015 revised release, RVU15A file http://www.cms.gov/Medicare/
Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files-Items/RVU15A.html?DLPage=1&DLSort=0&DLSortDir=descending
3 Source: November 10, 2014 Federal Register CMS-1613-FC.
4 National average (wage index greater than one) DRG rates calculated using the national adjusted full update standardized labor, non-labor and capital
amounts ($5,865.48). Source: August 22, 2014 Federal Register.
5 The patient’s medical record must support the existence and treatment of the complication or comorbidity.
6 May include but is not limited to one of the following hemostasis techniques: injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma
coagulator.
7 Likely to pertain to bronchial thermoplasty only.
8 Based on estimate that non-Medicare payment for outpatient hospital services is 2.17 times Medicare payment. Source: High and Varying Prices for
Privately Insured Patients Underscore Hospital Market Power by Chapin White, Amelia M. Bond and James D. Reschovsky.
17
Footnotes
ENDO-47410-AF DEC2014
* Note: There is a separate facility and physician payment for outpatient hospital services. The values in this table refer to the outpatient hospital facility payment only.
APC Description 2015 Medicare National Average Payment3
0141 Level I Upper GI Procedures $745
0419 Level II Upper GI Procedures $1,064
0422 Level III Upper GI Procedures $1,914
0151 Endoscopic Retrograde Cholangio-Pancreatography (ERCP) $1,952
0384 GI Procedures with Stents $3,174
0121 Level I Tube or Catheter Changes or Repositioning $488
0676 Thrombolysis and Other Device Revisions $195
0142 Level I Small Intestine Endoscopy $852
0424 Level II Small Intestine Endoscopy $1,249
0143 Lower GI Endoscopy $790
0146 Level I Sigmoidoscopy and Anoscopy $494
0147 Level II Sigmoidoscopy and Anoscopy $827
0428 Level III Sigmoidoscopy and Anoscopy $1,657
0148 Level I Anal/Rectal Procedures $442
0076 Level I Endoscopy Lower Airway $1,055
0415 Level II Endoscopy Lower Airway $2,255
See important information about the uses and limitations of this document on pages 2 and 3 18
Hospital Outpatient Facility PaymentTable 1. Final 2015 Hospital Outpatient Payments for Endoscopy Services*
ENDO-47410-AF DEC2014
1 For devices packaged in kits, hospitals may bill for the components of the kits that individually qualify for C-Codes. Facilities should bill for the estimated proportion of the kit that the C-Code eligible device comprises.
C-Code C-Code Description Devices Impacted1
C1726 Catheter, balloon dilation, non-vascular
CRE™ Single-Use Fixed Wire Esophageal Balloon Dilators
CRE Single-Use Pulmonary Balloon Dilators
CRE Single-Use Wireguided Esophageal/Pyloric/Biliary Balloon Dilators
CRE Single-Use Wireguided Esophageal/Pyloric/Colonic/Biliary Balloon Dilators
CRE Single-Use Wireguided Biliary Balloon Dilators
Hurricane™ RX Single-Use Biliary Dilatation Balloon Catheters
MaxForce™ Biliary Balloon Dilatation Catheters
MaxForce TTS™ Single-Use Balloon Dilators
Rigiflex™ II Single-Use Achalasia Balloon Dilators
C1769 Guide wire All BSC guide wires used in GI procedures: Dreamwire™ Guidewire, Hydra Jagwire™ Guidewire, Jagwire™ Guidewire, Pathfinder™ Guidewire
C1874 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 – Distal Release
Ultraflex Single-Use Covered Esophageal NG Stent System – Proximal Release
Ultraflex Single-Use Covered Large Esophageal NG Stent System – Distal Release
Ultraflex Single-Use Covered Large Esophageal NG Stent System – Proximal Release
Ultraflex Single-Use Covered Tracheobronchial Stent System - Distal Release
WallFlex™ Biliary RX Fully Covered Stent System
WallFlex Biliary RX Partially Covered Stent System
WallFlex Fully Covered Esophageal Stent
WallFlex Partially Covered Esophageal Stent System
WALLSTENT™ Endoscopic Biliary Endoprosthesis Stents
C1875 Stent, coated/covered without delivery system Dynamic™ (Y) Stent
C1876 Stent, non-coated/non-covered, with delivery system
Ultraflex Precision Single-Use Colonic Stent System
Ultraflex Single-Use Uncovered Esophageal NG Stent System – Distal Release
Ultraflex Single-Use Uncovered Esophageal NG Stent System – Proximal Release
Ultraflex Single-Use Uncovered Tracheobronchial Stent System – Distal Release
Ultraflex Single-Use Uncovered Tracheobronchial Stent System – Proximal Release
WallFlex Single-Use Colonic Stent System
WallFlex Single-Use Duodenal Stent System
WallFlex Biliary RX Uncovered Stent System
WALLSTENT RX Biliary Endoprosthesis Stent System
WALLSTENT Endoscopic Biliary Endoprosthesis Stents
WALLSTENT Single-Use Colonic and Duodenal Endoprosthesis with UniStep™ Plus Delivery System
C2617 Stent, non-coronary, temporary, without delivery system
Advanix™ Biliary Stent
Advanix Pancreatic Stent
C-Flex™ Double Pigtail Biliary Stent
Percuflex™ Duodenal Bend Biliary Stents
C2625Stent, non-coronary, temporary, with delivery system
Advanix Preloaded Biliary Stent Systems
Advanix Pancreatic Stent Kits
Flexima™ Biliary Stent Systems
Percuflex Duodenal Bend Biliary Stent with Introducer Kit1
RX Biliary Stents with RX Delivery System™
C1886 Catheter, extravascular tissue ablation, any modality (insertable) Alair™ Bronchial Thermoplasty Catheter
See important information about the uses and limitations of this document on pages 2 and 3 19
Endoscopy C-Code Summary
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