LESS INVASIVE GERD procedures that let practitioners access the stomach via the mouth now have a special CPT code, but payers still have to accept the new approach.

If your facility is thinking about offering the innovative new approaches to treat gastroesaphogeal reflux disease (GERD), be warned that getting reimbursed might be a challenge.

"Everybody gets all excited when there's a new code out, but unfortunately, just because you get a code doesn't mean you're going to get paid on it," says Kathleen Mueller, RN, CPC, CCS-P, CMSCS, CGCS, CCC, a coding and reimbursement expert from Lenzburg, Ill., and the president of Ask Mueller Consulting.

She's referring to the new CPT Category 1 code (43210) covering esophagogastric fundoplasty trans-orifice procedures. It went into effect Jan. 1, and is being welcomed by the companies touting the TIF (EndoGastric) and MUSE (Medigus) procedures. In both procedures, the stomach is accessed via the mouth with specialized instruments used in conjunction with flexible endoscopes. The new tools let gastroenterologists and surgeons reconstruct the gastroesophageal valve and reestablish a barrier to reflux. The procedures, which are done under general anesthesia, are incision-less and quick, and have been FDA approved for years. But payer acceptance of new procedures tends to be anything but quick.

"Some payers consider it investigational, even though the devices have FDA approval," says Ms. Mueller. "They've been out for several years, but it's still not considered a traditional repair. Some are going to cover it, because there's much less expense doing it endoscopically, versus doing a lap or an open procedure."

So while a new CPT code is no guarantee, it's a big step in the right direction for companies pushing treatments that could become staples at outpatient facilities. "There was really no way to bill this before," says practice management consultant Elizabeth Woodcock, MBA, FACMPE, CPC, of Woodcock & Associates in Atlanta. "Physicians could report it using an unlisted code and have billers send in the medical record to try to justify the procedure. But when a code doesn't exist, it's impossible to get paid on the first go-round, and you have only about a 50-50 shot of getting paid even after you've explained your work."

The new code is likely to speed acceptance, says Robin McLendon, CPC, CPMA, coding compliance manager at Atlanta Gastroenterology Associates. "Whenever there's new technology, it seems like there are just a handful of physicians who will do it," she says, "but eventually others start to adopt it."

"If I were having this surgery, I'd rather have it done endoscopically as an outpatient," adds Ms. Mueller. "Unfortunately, you just don't see the payers jumping on this stuff."

For physicians who use either of the new endoscopic procedures covered by the new code, the national unadjusted payment value is $445.34. For outpatient facilities, the national unadjusted payment value, under the corresponding code C-APC5331 ("complex GI procedures") is $3,613.57.

But as the American Gastroenterological Association notes, by classifying the new code under "complex GI procedures" and assigning a status indicator of "J1," CMS signaled disagreement with some advocates and determined that payments for the procedure should be bundled. "Unfortunately, that means on the facility side you can only bill one code," says Ms. Woodcock. "You can't bill supplies or anything extra."

History is replete with examples of new approaches that have been hindered by slow-to-accept payers. The Stretta system, an endoscopic approach to GERD that was cleared by the FDA in 2000, is still battling for acceptance, says Ms. Mueller. The procedure uses radiofrequency energy to remodel and improve muscle tissue between the stomach and esophagus, resulting, in most cases, in improved barrier function.

Stretta has a CPT code (43257), but "a lot of payers still aren't covering it," says Ms. Mueller. Instead, she says, payers tend to look more favorably on "traditional" open approaches, such as fundoplasty with a fundic patch (43325), laparotomy (43327) and thoracotomy (43328). The laparoscopic Nissen approach (43280) has also been widely accepted by payers and is now the most common procedure overall, she says.

LINX REFLUX MANAGEMENT
Magnetic Bead Procedure Awaits CPT Code

HEALING FORCE The LINX system uses a small band of interlinked magnetic beads that prevent passage from the stomach to the esophagus.

Also trumpeting the impending arrival of a new CPT code is the company behind the LINX reflux management system, a laparoscopic procedure that treats GERD by implanting a small flexible band of interlinked magnetic titanium beads around the lower esophageal sphincter, thus allowing only one-way passage from the esophagus to the stomach. The mechanism lets the forces that are used to swallow break the magnetic bond, allowing food and liquid to pass. When the magnets pull back together, they create a barrier to reflux.

Torax Medical, the company behind LINX, says the CPT code covering it won't be effective until Jan. 1, 2017, something that might raise flags, says Kathleen Mueller, RN, CPC, CCS-P, CMSCS, CGCS, CCC, a coding and reimbursement expert from Lenzburg, Ill., and the president of Ask Mueller Consulting. "A lot of times they (the AMA) give preliminary codes, but that doesn't mean they'll still go into effect," she says. "Sometimes at the last minute they change their minds and say no. It's always a 'may' until it gets published." Final determinations on CPT codes are released in the fall.

Nothing is certain, acknowledges Rich Pilon, Torax's vice-president of global healthcare policy and reimbursement. "There are 3 distinct processes: coding, payment and coverage," he says. "The fact that we have a Category 1 CPT code assigned to us is a major hurdle, but there are 2 that remain. The next thing is the (determination of) relative value units. And the last piece is the coverage piece." In other words, whether payers will be willing to cover the procedure.

But Mr. Pilon hopes the company won't have to wait until next January. "If everything goes our way, we'll have some coverage policies prior to the CPT code taking effect," he says. That would require payers to agree to reimburse facilities under the current CPT Category III code, 0392T. (Category III codes are temporary codes for new and emerging technologies.) He says Torax is negotiating with private payers, trying to get a head start.

But Category III codes always end in "T," as in "temporary," and, says Ms. Mueller: "Medicare won't pay anything with a T behind it. You would still have to bill as an unlisted procedure." And as far as commercial payers go, "some will accept it and some will not."

— Jim Burger

Trust but verify
The bottom line is that while physicians might be extremely enthusiastic about a given new procedure, neither they nor the facilities they work in can afford to do it if they're not going to get paid.

"Verification eligibility is essential," says Ms. Mueller. "And it's important to remember that obtaining pre-authorization is just 1 step in a 2-step process. Pre-authorization is when we find out whether we need to get a procedure approved. For outpatient procedures, most of the time pre-authorization isn't a requirement, but you still have to call and tell them it's being done. But at the end of the conversation, they'll always say, this is not a guarantee of payment, did you verify the patient's eligibility? That's where you find out if this is considered an experimental procedure by this payer." OSM