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New Lower Endoscopy CPT Codes Not Recognized Under MPFS for 2015

March 25, 2015:

Although the American Medical Association (AMA) made significant revisions to the procedure codes for lower gastrointestinal endoscopies for 2015, complete with additions, deletions, and revisions, Medicare fee-for-service and Medicare Advantage plans are not going along with the redesign, at least not for this year.

For those claims paid under the Medicare physician fee schedule (MPFS), little will change—the Centers for Medicare and Medicaid Services (CMS) is not recognizing the new codes for physician payment and is keeping policies and code values the same this year as for last. Where the AMA has deleted codes, CMS has created HCPCS Level II G codes to enable physicians to report their services similarly to the way they did in 2014.

CMS is not recognizing AMA’s revisions because of concerns over misvaluation of the procedures, especially those that include moderate sedation. It plans to examine the code values and the role moderate sedations plays this year and be ready to recognize the AMA’s codes in 2016, along with new valuations.

For calendar year 2015, CMS will maintain the MPFS inputs for the lower gastrointestinal endoscopy codes at the CY 2014 levels. Since the AMA changed the code set for CY 2015, including some deletions, CMS has created HCPCS Level II G codes to fill in the gaps. All payment policies applicable to the CY 2014 CPT codes will apply to the replacement G codes.

Under CY 2015 MPFS, the new lower endoscopy codes the AMA created have a status indicator of “I”(invalid), meaning that the code is not valid for Medicare purposes. In these instances, practitioners are to report the HCPCS Level II G code in place of the invalid Medicare code as indicated in the table below. Additionally, the multiple endoscopic payment rules apply, and the endoscopy base codes for the Medicare required G codes are also provided when identified by CMS.

CPT Code Deleted for 2015 AMA Recommended 2015 CPT Code HCPCS Code Endo Base for HCPCS Level II When Assigned by CMS Short Description
4438344384 G6018 Ileoscopy w/stent
4439344401 G601944388Colonoscopy lesion removal
4439744402 G602044388Colonoscopy w/stent
44799*44799 G6021 Unlisted px small intestine
4533945346 G602245330 Sigmoidoscopy w/ablate tumr
4534545347 G602345330 Sigmoidoscopy w/stent
4538345388 G602445378 Colonoscopy w/stent
0226T 46601 G6027 Anoscopy HRA w/spec collect
0227T 46607 G6028 Anoscopy HRA w/biopsy

*This is an unlisted code and was not deleted. However, there are 2015 CPT and HCPCS Level II codes that accurately describe the procedure that was reported using an unlisted procedure code previously.

The new CPT codes not paid under the MPFS are 44381, 44384, 44401–44408, 45346, 45347, 45349, 45350, 45388–45390, 45393, 45398, 45399, 46601, and 46607. They have relative value units of 0.00 for 2015.

Practices should check with Medicaid and other payers before reporting the 2015 CPT or G codes to determine which coding system the payer requires. Issues can arise, however, when Medicare is the secondary payer and the primary payer requires providers to use the 2015 CPT code. In these cases, in may be necessary for providers to resubmit the claim to Medicare after changing the 2015 CPT code to the appropriate HCPCS Level II G code as noted in the table above. Note that, for Medicare, hospitals and ambulatory surgery centers will report the CPT codes as the AMA has updated them, including the new and revised codes.


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