SPECIAL ARTICLE Coding for ‘‘deep enteroscopy’’ procedures in an era of emerging technology In 2001, Hironori Yamamoto introduced an entero- scope that was fitted with an inflatable balloon at the tip combined with a flexible overtube that was also equip- ped with a balloon. 1 By sequentially inflating and deflating the balloons, and by advancing and withdrawing the en- teroscope and overtube, he was able to demonstrate that deep, and at times, complete, small-bowel entero- scopy could be performed antegrade, via the mouth, or retrograde, via the anus. Combining these two procedures led to complete enteroscopy in a significant number of patients. Over the past 6 years, numerous studies con- firmed that ‘‘double-balloon enteroscopy’’ (DBE) can in- deed enable deep enteroscopy by both routes. 2,3 Yet, these studies also pointed out that DBE is time consum- ing, physically demanding, and resource intensive. Within the past year, at least 3 other methods for performing deep enteroscopy (DE) have been described, and it is likely that additional technologies for this purpose lie just over the horizon. Like many new technologies, DE has evolved faster than existing codes and current reimbursement. When new medical technologies are introduced, they often are performed for a period of time by early adopters before Current Procedural Terminology (CPT) codes are created by the American Medical Association (AMA). If ex- isting category I codes adequately describe the new proce- dure, then there is generally no utility in applying for new codes. Once a category I code is created, it is referred to the AMA’s Specialty Society Relative Value Update Commit- tee (RUC) for their recommendations regarding physician work and practice expense. The RUC recommendations are then forwarded to the Centers for Medicare and Med- icaid Services (CMS), which then establishes the Medicare Physician Fee Schedule reimbursement for the procedure. Under Medicare regulations, codes can be reevaluated periodically through a 5-year review process to take into account new techniques and/or technologies in the per- formance of the procedure. Reimbursement may be deval- ued as part of that review if there is a reduction in the physician work involved. If no code adequately describes a new procedure or technology, anybody, whether an individual, a corporation, or a specialty society, may petition the CPT Editorial Panel to establish a new one. The Editorial Panel may recom- mend that new and emerging technologies are assigned a category III tracking code when there is insufficient liter- ature published in U.S. peer-reviewed journals to support the procedure. Although a category III status does not as- cribe a relative value unit (RVU) level to the procedure, this allows tracking of the procedure for the possible fu- ture establishment of a category I code. Societies and in- dustry often try to avoid category III codes, even with new technologies, because there is a perception that cat- egory III status can limit payment for the procedure, not only by CMS, but also by private insurers. This has not al- ways been borne out, as evidenced by Medicare carriers in most states and many commercial insurers who pay for code 0067T, computed tomographic (CT) colonography (ie, virtual colonoscopy). For a coding change application to be successful as a category I code, the petitioners must indicate whether the procedure is performed in a few spe- cialized centers or many centers. In addition, the peti- tioners should provide an estimate of the average number of procedures that would be performed in a calen- dar year. If the CPT Editorial Panel recommends that a category I code should be created, then the specialty societies must perform a physician work survey and submit the survey re- sults to the RUC for evaluation. The survey data regarding the procedure should be obtained from practitioners, in clinical practice in multiple locations, who are familiar with the procedure. Although no number is specified, the RUC has indicated that survey validity is questionable when fewer than 30 surveys are completed. Because Part B of Medicare is a budget neutral program, the successful creation of a new code does not increase the pool of money available. Rather, a new code adds an additional factor by which the static pool of money must be divided to maintain a ‘‘zero-sum’’ system, which raises the risk that creating new codes can decrease physician work reimbursement for ex- isting codes. DE provides a unique challenge for gastroenterologists, because several codes already exist that describe the procedure. The 44360 family describes small-intestinal en- doscopy or enteroscopy beyond second portion of duode- num, not including the ileum. Additional codes describe Copyright ª 2008 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2007.12.029 www.giejournal.org Volume 67, No. 3 : 2008 GASTROINTESTINAL ENDOSCOPY 391