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3/16/96
I am having difficulty with reimbursement, primarily from Medicare. They have refused to pay for my rectal and rectosigmoid evaluations, claiming these are investigational. I am coding for flexible sigmoidoscopy and ultrasound, +/- FNA. They will not pay even if I change the coding. Has anyone had similar experience, how was it handled? Would appreciate any advice.
APlumser@AOL.com (Allan Plumser)
3/17/96
This is clearly the next area with regard to reimbursement that we as a group need to focus on. I have recently brought these issues to the attention of our business office at Duke. Until we have a CPT code and RVU assigned to rectal EUS, we have decided to try a nonspecific CPT code (43599) which will be accompanied by a memo explaining the procedure. I am not optimistic about its future success. Another alternative is to use the CPT code for a transrectal ultrasound as it is used by radiologists (76872) but the reimbusement for this is a very small amount. It certainly doesn't compensate for all the time, skills, and liability risks that are associated with these exams. You can find more information about CPT codes at the AEC website (URL http://www.duke.edu/eus/).
I am convinced that the insurance companies will do what ever they can to avoid paying anything that they aren't forced to pay. That is why the American Endosonography Club (AEC) should initiate efforts to obtain a CPT code from the AMA for rectal EUS. Once this is done we should go to battle again with HCFA to obtain a fair RVU. This was not attempted at the time we got the upper EUS CPT code because, as I understand it, it would have jeapordized our chance for getting any CPT code at all for EUS. Arnie Rosen M.D.(former ASGE rep. for reimbursment issues) probably knows more about those details. None-the-less, this may be the time to "start the ball rolling" again for obtaining a rectal EUS CPT code and RVU.
I will send your message in to the EUS e-mail group to see if any one else has any comments. It will also be posted on the AEC website bulletin board.
John Affronti M.S, M.D.
Director of Gastrointestinal Endosonography
Assistant Professor of Medicine
Duke University Medical Center