2011 Coding and Reimbursement Guide for Procedures Involving the NaviAid ™ AB and NaviAid ™ABC Devices

DESCRIPTION OF PAYMENT METHODS

Physician Billing and Payment Medicare payment for inpatient hospital services is based Medicare and most other insurers typically reimburse on a classification system determined by patient physicians based on fee schedules according to CPT diagnosis known as Medicare Severity - Diagnosis Codes. The CPT Codes are published by the American Related Groups (MS-DRGs). MS-DRGs are based on the Medical Association (AMA) and are used to report assumption that economic incentives can be used to medical procedures and services under public and private improve hospital efficiency, thus containing health care health insurance programs. expenditures. Fixed prices are established for hospital services based on the patient’s diagnosis and are paid regardless of the actual cost the hospital incurs in providing these services. Only one MS-DRG is assigned Hospital Outpatient Billing and Payment to a patient for a particular hospital admission. Therefore, one payment is made per patient and that payment is A hospital outpatient department is administratively and based upon the MS-DRG assignment. financially linked to a hospital and the services are performed for patients who are registered at the hospital A sampling of MS-DRGs that may apply to procedures but are not admitted as an inpatient, i.e. .no overnight involving the use of the NaviAid™ AB and NaviAid™ ABC stay. devices are as follows: The Hospital Outpatient Prospective Payment System is based on groups of procedures, medical visits, and MS- MS-DRG ancillary services referred to as Ambulatory Payment DRG Description Rate 2 Classifications (APCs). The services within each group 326 , Esophageal & Duodenal Procedures W MCC $32,467.23 are similar clinically and in relative resource use. 327 Stomach, Esophageal & Duodenal Procedures W CC $15,206.35 Assignment of APC grouping is based on CPT codes. 328 Stomach, Esophageal & Duodenal Procedures W/O CC/MCC $ 7,984.12 329 Major Small & Large Bowel Procedures W MCC $29,488.24 330 Major Small & Large Bowel Procedures W CC $14,423.81 Hospital Inpatient Billing and Payment 331 Major Small & Large Bowel Procedures W/O CC/MCC $ 9,083.84 344 Minor Small & Large Bowel Procedures W MCC $17,638.26 ICD-9-CM procedure codes 1 are used to report 345 Minor Small & Large Bowel Procedures W CC $ 9,512.81 procedures performed in a hospital inpatient setting. The following are a few of the ICD-9-CM procedure codes that 346 Minor Small & Large Bowel Procedures W/O CC/MCC $ 6,635.45 may be appropriate for the procedures involving the use 374 Digestive Malignancy W MCC $11,544.33 of NaviAid™ AB and NaviAid™ ABC devices: 375 Digestive Malignancy W CC $ 7,148.29 376 Digestive Malignancy W/O CC/MCC $ 4,734.28 Procedure Description CC = Complications and Comorbidites Code MCC = Major Complications and Comobidites 44.32 Percutaneous [endoscopic] gastrojejunostomy 44.43 Endoscopic control of gastric or duodenal bleeding 45.13 Other endoscopy of 45.14 Closed [endoscopic] of small intestine Ambulatory Surgical Centers (ASC) Billing and 45.16 Esophagogastroduodenoscopy (EGD) with closed Payment biopsy 45.23 An Ambulatory Surgical Center is a free-standing clinic 45.25 Closed [endoscopic] biopsy of outside the hospital setting. As in the hospital outpatient 45.30 Endoscopic excision or destruction of lesion of setting payment system, the ASC payment system is also 45.42 Endoscopic polypectomy of large intestine based on the APC grouping. Medicare has a list of 45.43 Endoscopic destruction of other lesion or tissue of services that are covered in the ASC setting. Not all large intestine services that Medicare covers in the hospital outpatient 46.32 Percutaneous (endoscopic) (PEJ) setting are eligible for payment in ASCs. 46.79 Other repair of intestine 46.85 Dilation of intestine 46.86 Endoscopic insertion of colonic stent(s) 51.10 Endoscopic retrograde cholangiopancreatography [ERCP]

Providers should select the most appropriate procedure code(s) to describe the services provided to the patient.

DISCLAIMER: THE INFORMATION PROVIDED WITH THIS NOTICE IS GENERAL REIMBURSEMENT INFORMATION ONLY AS OF APRIL 2011; IT IS NOT LEGAL ADVICE, NOR IS IT ADVICE ABOUT HOW TO CODE, COMPLETE OR SUBMIT ANY PARTICULAR CLAIM FOR PAYMENT. ALTHOUGH WE SUPPLY THIS INFORMATION ACCORDING TO OUR CURRENT KNOWLEDGE, IT IS ALWAYS THE PROVIDER’S RESPONSIBILITY TO DETERMINE AND SUBMIT APPROPRIATE CODES, CHARGES, MODIFIERS AND BILLS FOR THE SERVICES THAT WERE RENDERED. THIS INFORMATION IS PROVIDED AS OF THE DATE LISTED ABOVE, AND ALL CODING AND REIMBURSEMENT INFORMATION IS SUBJECT TO CHANGE WITHOUT NOTICE. REIMBURSEMENT INFORMATION PROVIDED BY SMART MEDICAL SYSTEMS LTD. IS GATHERED FROM THIRD-PARTY SOURCES AND PRESENTED FOR ILLUSTRATIVE PURPOSES ONLY. PAYERS OR THEIR LOCAL BRANCHES MAY HAVE THEIR OWN CODING AND REIMBURSEMENT REQUIREMENTS AND POLICIES. BEFORE FILING ANY CLAIMS, PROVIDERS SHOULD VERIFY CURRENT REQUIREMENTS AND POLICIES WITH THE PAYER.

MEDICARE PHYSICIAN, HOSPITAL OUTPATIENT AND ASC PAYMENT

The following are the CPT codes that may apply when procedures using the NaviAid™ AB and NaviAid™ ABC devices are performed. Also included are the 2011 national Medicare Physician Fee Schedule (MPFS), Hospital Outpatient Ambulatory Payment Category (APC) and Ambulatory Surgical Center (ASC) payment rates. Payment will vary in geographic locality.

2011 Medicare Reimbursement (National Average) CPT 3 Code Descriptions Physician Facility Code 4 5 Hospital 7 Office Facility 6 ASC Outpatient UPPER ENDOSCOPY / / ILEOSCOPY Upper gastrointestinal endoscopy including , stomach, and either the duodenum and/or as appropriate; diagnostic, with or 43235 $297.97 $148.14 $611.73 $344.10 without collection of specimen(s) by brushing or washing (separate procedure) Upper gastrointestinal endoscopy including esophagus, stomach, and 43236 either the duodenum and/or jejunum as appropriate; with directed $369.32 $179.00 $611.73 $344.10 submucosal injection(s), any substance Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with endoscopic 43237 $240.55* $240.55 $611.73 $344.10 ultrasound examination limited to the esophagus

Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with 43238 transendoscopic ultrasound-guided intramural or transmural fine $300.01* $300.01 $611.73 $344.10 needle aspiration/biopsy(s), esophagus (includes endoscopic ultrasound examination limited to the esophagus) Upper gastrointestinal endoscopy including esophagus, stomach, and 43239 either the duodenum and/or jejunum as appropriate; with biopsy, single $345.20 $174.64 $611.73 $344.10 or multiple

Upper gastrointestinal endoscopy including esophagus, stomach, and 43240 either the duodenum and/or jejunum as appropriate; with transmural $405.00* $405.00 $611.73 $344.10 drainage of pseudocyst

Upper gastrointestinal endoscopy including esophagus, stomach, and 43241 either the duodenum and/or jejunum as appropriate; with $158.67* $158.67 $611.73 $344.10 transendoscopic intraluminal tube or catheter placement Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transendoscopic ultrasound-guided intramural or transmural fine 43242 $432.52* $432.52 $1,148.75 $646.18 needle aspiration/biopsy(s) (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum and/or jejunum as appropriate) Upper gastrointestinal endoscopy including esophagus, stomach, and 43243 either the duodenum and/or jejunum as appropriate; with injection $273.17* $273.17 $611.73 $344.10 sclerosis of esophageal and/or gastric varices

Upper gastrointestinal endoscopy including esophagus, stomach, and 43244 either the duodenum and/or jejunum as appropriate; with band ligation $301.71* $301.71 $611.73 $344.10 of esophageal and/or gastric varices

Upper gastrointestinal endoscopy including esophagus, stomach, and 43245 either the duodenum and/or jejunum as appropriate; with dilation of $191.97* $191.97 $611.73 $344.10 gastric outlet for obstruction (eg, balloon, guide wire, bougie)

Upper gastrointestinal endoscopy including esophagus, stomach, and 43246 either the duodenum and/or jejunum as appropriate; with directed $256.86* $256.86 $611.73 $344.10 placement of percutaneous tube

Upper gastrointestinal endoscopy including esophagus, stomach, and 43247 either the duodenum and/or jejunum as appropriate; with removal of $204.54* $204.54 $611.73 $344.10 foreign body

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2011 Medicare Reimbursement (National Average) CPT 3 Code Descriptions Physician Facility Code 4 5 Hospital 7 Office Facility 6 ASC Outpatient

Upper gastrointestinal endoscopy including esophagus, stomach, and 43248 either the duodenum and/or jejunum as appropriate; with insertion of $192.31* $192.31 $611.73 $344.10 guide wire followed by dilation of esophagus over guide wire

Upper gastrointestinal endoscopy including esophagus, stomach, and 43249 either the duodenum and/or jejunum as appropriate; with balloon $177.36* $177.36 $611.73 $344.10 dilation of esophagus (less than 30 mm diameter) Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of 43250 $192.65* $192.65 $611.73 $344.10 tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery Upper gastrointestinal endoscopy including esophagus, stomach, and 43251 either the duodenum and/or jejunum as appropriate; with removal of $222.55* $222.55 $611.73 $344.10 tumor(s), polyp(s), or other lesion(s) by snare technique

Upper gastrointestinal endoscopy including esophagus, stomach, and 43255 either the duodenum and/or jejunum as appropriate; with control of $288.46* $288.46 $611.73 $344.10 bleeding, any method

Upper gastrointestinal endoscopy including esophagus, stomach, and 43256 either the duodenum and/or jejunum as appropriate; with $260.26* $260.26 $1,915.43 $1,077.45 transendoscopic stent placement (includes predilation) Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with delivery of 43257 $324.81* $324.81 $611.73 $344.10 thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with ablation of 43258 $272.49* $272.49 $611.73 $344.10 tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with endoscopic 43259 $310.20* $310.20 $611.73 $344.10 ultrasound examination, including the esophagus, stomach, and either the duodenum and/or jejunum as appropriate Small intestinal endoscopy, enteroscopy beyond second portion of 44360 duodenum, not including ; diagnostic, with or without collection of $160.71* $160.71 $701.55 $394.63 specimen(s) by brushing or washing (separate procedure)

Small intestinal endoscopy, enteroscopy beyond second portion of 44361 $176.68* $176.68 $701.55 $394.63 duodenum, not including ileum; with biopsy, single or multiple

Small intestinal endoscopy, enteroscopy beyond second portion of 44363 $210.65* $210.65 $701.55 $394.63 duodenum, not including ileum; with removal of foreign body

Small intestinal endoscopy, enteroscopy beyond second portion of 44364 duodenum, not including ileum; with removal of tumor(s), polyp(s), or $225.60* $225.60 $701.55 $394.63 other lesion(s) by snare technique

Small intestinal endoscopy, enteroscopy beyond second portion of 44365 duodenum, not including ileum; with removal of tumor(s), polyp(s), or $201.48* $201.48 $701.55 $394.63 other lesion(s) by hot biopsy forceps or bipolar cautery Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with control of bleeding (eg, injection, 44366 $265.36* $265.36 $701.55 $394.63 bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with ablation of tumor(s), polyp(s), or 44369 $271.13* $271.13 $701.55 $394.63 other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique Small intestinal endoscopy, enteroscopy beyond second portion of 44370 duodenum, not including ileum; with transendoscopic stent placement $292.88* $292.88 $1,915.43 $1,077.45 (includes predilation)

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2011 Medicare Reimbursement (National Average) CPT 3 Code Descriptions Physician Facility Code 4 5 Hospital 7 Office Facility 6 ASC Outpatient

Small intestinal endoscopy, enteroscopy beyond second portion of 44372 duodenum, not including ileum; with placement of percutaneous $260.60* $260.60 $701.55 $394.63 jejunostomy tube

Small intestinal endoscopy, enteroscopy beyond second portion of 44373 duodenum, not including ileum; with conversion of percutaneous $209.63* $209.63 $701.55 $394.63 gastrostomy tube to percutaneous jejunostomy tube

Small intestinal endoscopy, enteroscopy beyond second portion of 44376 duodenum, including ileum; diagnostic, with or without collection of $310.20* $310.20 $701.55 $394.63 specimen(s) by brushing or washing (separate procedure)

Small intestinal endoscopy, enteroscopy beyond second portion of 44377 $328.21* $328.21 $701.55 $394.63 duodenum, including ileum; with biopsy, single or multiple

Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with control of bleeding (eg, injection, 44378 $421.31* $421.31 $701.55 $394.63 bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) Small intestinal endoscopy, enteroscopy beyond second portion of 44379 duodenum, including ileum; with transendoscopic stent placement $446.45* $446.45 $1915.43 $1077.45 (includes predilation)

Carrier Carrier Carrier 44799 Unlisted procedure, intestine $1,824.04 Priced Priced Priced

COLONOSCOPY Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with 45378 or without collection of specimen(s) by brushing or washing, with or $395.83 $220.85 $643.41 $361.93 without colon decompression (separate procedure)

Colonoscopy, flexible, proximal to splenic flexure; with removal of 45379 $504.89 $276.23 $643.41 $361.93 foreign body

Colonoscopy, flexible, proximal to splenic flexure; with biopsy, 45380 $472.95 $264.68 $643.41 $361.93 single or multiple

Colonoscopy, flexible, proximal to splenic flexure; with control of 45382 bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, $619.39 $337.73 $643.41 $361.93 heater probe, stapler, plasma coagulator)

Colonoscopy, flexible, proximal to splenic flexure; with ablation of 45383 tumor(s), polyp(s), or other lesion(s) not amenable to removal by $568.09 $341.46 $643.41 $361.93 hot biopsy forceps, bipolar cautery or snare technique

Colonoscopy, flexible, proximal to splenic flexure; with removal of 45384 tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar $468.19 $275.89 $643.41 $361.93 cautery

Colonoscopy, flexible, proximal to splenic flexure; with dilation by 45386 $270.79 $661.18 $643.41 $361.93 balloon, 1 or more strictures

Colonoscopy, flexible, proximal to splenic flexure; with 45387 $351.66* $351.66 $1915.43 $1077.45 transendoscopic stent placement (includes predilation)

Colonoscopy, flexible, proximal to splenic flexure; with endoscopic 45391 $301.71* $301.71 $643.41 $361.93 ultrasound examination

Colonoscopy, flexible, proximal to splenic flexure; with 45392 transendoscopic ultrasound guided intramural or transmural fine $387.67* $387.67 $643.41 $361.93 needle aspiration/biopsy(s) 4

2011 Medicare Reimbursement (National Average) CPT 3 Code Descriptions Physician Facility Code 4 5 Hospital 7 Office Facility 6 ASC Outpatient

Carrier Carrier Carrier 44799 Unlisted procedure, intestine $1,824.04 Priced Priced Priced

Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or 45378- without collection of specimen(s) by brushing or washing, with or $137.60 $63.20 $388.3 $91.08 53 without colon decompression (separate procedure) (incomplete colonoscopy NOT reaching the splenic flexure) COLONOSCOPY WITH DEEP ILEOSCOPY

Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with

or without collection of specimen(s) by brushing or washing, with or $395.83 $220.85 $643.41 $361.93 45378 without colon decompression (separate procedure)

And Carrier Carrier Carrier 44799 $1,824.04 Unlisted procedure, intestine Priced Priced Priced

Or Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or 45378- Carrier Carrier Carrier Carrier without collection of specimen(s) by brushing or washing, with or 22 Priced Priced Priced Priced without colon decompression (separate procedure)

* The Centers for Medicare & Medicaid Services (CMS) has not established a practice expense relative value units (PE RVU) in the non-facility setting for this service because it is typically performed in the hospital. Therefore, if the contractor determines that this service can be performed in the non-facility setting the service will be paid at the facility rate.

Modifiers -22 Increased procedural services -53 Discontinued procedure

This information provided by Smart Medical Systems Ltd. is not intended to increase or maximize reimbursement by any third party payer. The information is intended to assist providers in accurately obtaining coverage and reimbursement for health care goods and services. Ultimate responsibility for correct coding lies with the provider of the service. Please contact the payer for their interpretation of the appropriate codes to use to report of the procedures involving the use of the NaviAid.

1 Hospital ICD-9-CM 2011 Volumes 1,2, & 3, 9th Revision-Clinical Modification, Ingenix. Copyright © 2010 Ingenix, Inc. 2 Federal Register / Vol. 75, No. 157 / Monday, August 16, 2010. Note: The payment amounts indicated are estimates only based upon data elements derived from various CMS sources. These sources include the 8/16/10 Federal Register and the hospital payment impact file dated 7/30/10. Calculations assume that all hospitals are receiving the full 2.35% quality reporting update. Actual payment may vary based on various hospital-specific factors not reflected in the source data. Providers indicated by an asterisk (*) may be paid based on a methodology, which differs from the standard MS-DRG payment calculation reflected in the amount shown (i.e., rural referral centers, hospitals in the state of Maryland). Actual payment may also vary based on adjustments that CMS may make from time to time. 3CPT codes and descriptions only are copyright © 2010 American Medical Association. All rights reserved. No fee schedules are included in CPT. The American Medical Association assumes no liability for data contained or not contained herein. 4 Federal Register / Vol. 75, No. 228 / Monday, November 29, 2010 Note: The payment amounts indicated are based upon legislative action and data elements published in the federal register by CMS 12/28/10. These changes are effective for services provided from 1/1/11 through 12/31/11. CMS may make adjustments to any or all of the data inputs from time to time. All CPT codes are copyright AMA. 5 Ibid. 6 Federal Register / Vol. 75, No. 226 / Wednesday, November 24, 2010 Note: The payment amounts indicated are estimates only based upon data elements derived from various CMS sources. These sources include CMS-1504-FC published on 11/2/10 and the IPPS hospital payment impact file published 7/30/10. Actual payment may vary based on various hospital-specific factors not reflected in the source data. Actual payment may also vary based on adjustments that CMS may make from time to time. 7Federal Register / Vol. 75, No. 226 / Wednesday, November 24, 2010

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