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PAP515

Physician Criteria for Gastroenterology Procedures


Provider Administrative Policy

Section
Physician
Policy Date
August 2010
Status/Date
New/August 2010
Provider Type(s)
Physician  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Policy

Physician Criteria for Gastroenterology Procedures

Blue Cross of Idaho strives to promote reasonable and consistent quality and safety requirements for providers of routine gastroenterology screening and diagnostic procedures. This policy illustrates the standards and minimal experience a member would associate with quality gastroenterology procedures and outcomes.  We are establishing minimum requirements to adjust rates for qualified physicians who perform procedures with the following CPT codes:

 43235  43239  45378  45380  45383  45384  45385

Board certified gastroenterologists are eligible for adjusted rates. Non-board certified physicians who want to qualify for the adjusted rates may submit evidence of the specific requirements as stated below to a provider relations specialist (see PAP100). A Blue Cross of Idaho Medical Director will review the evidence to determine if the physician has met  the requirements to qualify for the adjusted rates. We will communicate the results of this review to the requesting physician in writing within 30 days of the receipt of the complete submitted evidence.    

The requirements apply to in-network physicians for Traditional, PPO and/or POS lines of business, collectively or individually, after April 1, 2010. In-network physicians not currently board certified who perform the procedures in the first paragraph, are exempt from meeting this requirement. 

Specific Requirements for Physicians

Procedure Case Log

  • EGD (esophagogastroduodenoscopy) with or without biopsy 100 procedures
  • Total colonoscopy with or without biopsy 100 procedures; including 20 snare polypectomies
  • Hemostasis (upper and lower) 20 procedures 
  • Flexible sigmoidoscopy with or without biopsy 25 procedures
  •  PEG (percutaneous endoscopic gastrostomy) 20 procedures
  • Esophageal dilatation 20 procedures; including bougie; guidewire and balloon
  • ERCP(endoscopic retrograde cholangiopancreatography procedure) – 40 cases with 10 annual papillotomies
  • Stent placement minimum of 40 procedures  

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