23-195m Changes to Endoscopy Matrix
Date: 02/28/23
Effective January 1, 2023, the Health Net Endoscopy Matrix changed to reflect Diagnostic Testing and Therapeutic (Surgical) procedure classifications as follows:
- 14 new CPT1 codes
Classification applies regardless of place of service. The listed changes differentiate each code by classification type of diagnostic or therapeutic. These are abbreviations for Diagnostic Testing and Therapeutic (Surgical) in the Division of Financial Responsibility (DOFR).
The Health Net Endoscopy Matrix is used to reflect the DOFR between Health Net and capitated providers. The matrix is not intended to be used to determine a patient’s covered benefits or copayment obligations.
The Endoscopy Matrix (PDF) is available in the Provider Library.
Financial responsibility
Ambulatory surgical centers (ASCs) and hospitals are advised to refer to the Endoscopy Matrix upon receipt of referrals for endoscopic procedures to identify the appropriate classification and confirm who is financially responsible for endoscopic procedures before rendering services. Providers must submit claims to the appropriate payer.
Capitated participating physician groups (PPGs) should refer to the product-specific Provider Participation Agreement (PPA) DOFR to determine the payer with financial responsibility.
New additions to the endoscopy matrix
CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.
CPT Code | Description of Endoscopy | Diagnostic | Therapeutic (Surgical) |
|---|---|---|---|
0781T | Bronchoscopy, rigid or flexible, with insertion of esophageal protection device and circumferential radiofrequency destruction of the pulmonary nerves, including fluoroscopic guidance when performed; bilateral mainstem bronchi |
| X |
0782T | Bronchoscopy, rigid or flexible, with insertion of esophageal protection device and circumferential radiofrequency destruction of the pulmonary nerves, including fluoroscopic guidance when performed; unilateral mainstem bronchus |
| X |
43290 | Esophagogastroduodenoscopy, flexible, transoral; with deployment of intragastric bariatric balloon |
| X |
43291 | Esophagogastroduodenoscopy, flexible, transoral; with removal of intragastric bariatric balloon(s) |
| X |
C7509
| Bronchoscopy, rigid or flexible, diagnostic with cell washing(s) when performed, with computer-assisted image-guided navigation, including fluoroscopic guidance when performed | X |
|
C7510
| Bronchoscopy, rigid or flexible, with bronchial alveolar lavage(s), with computer-assisted image-guided navigation, including fluoroscopic guidance when performed |
| X |
C7511 | Bronchoscopy, rigid or flexible, with single or multiple bronchial or endobronchial biopsy(ies), single or multiple sites, with computer-assisted image-guided navigation, including fluoroscopic guidance when performed | X |
|
C7512 | Bronchoscopy, rigid or flexible, with single or multiple bronchial or endobronchial biopsy(ies), single or multiple sites, with transendoscopic endobronchial ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic intervention(s) for peripheral lesion(s), including fluoroscopic guidance when performed | X |
|
C7541 | Diagnostic endoscopic retrograde cholangiopancreatography (ERCP), including collection of specimen(s) by brushing or washing, when performed, with endoscopic cannulation of papilla with direct visualization of pancreatic/common bile ducts(s) | X |
|
C7542 | Endoscopic retrograde cholangiopancreatography (ERCP) with biopsy, single or multiple, with endoscopic cannulation of papilla with direct visualization of pancreatic/common bile ducts(s) | X |
|
C7543 | Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy/papillotomy, with endoscopic cannulation of papilla with direct visualization of pancreatic/common bile ducts(s) |
| X
|
C7544 | Endoscopic retrograde cholangiopancreatography (ERCP) with removal of calculi/debris from biliary/pancreatic duct(s), with endoscopic cannulation of papilla with direct visualization of pancreatic/common bile ducts(s) |
| X |
C7550 | Cystourethroscopy, with biopsy(ies) with adjunctive blue light cystoscopy with fluorescent imaging agent |
| X |
C7554 | Cystourethroscopy with adjunctive blue light cystoscopy with fluorescent imaging agent |
| X |
Additional information
Relevant sections of Health Net’s provider operations manuals have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library.
If you have questions regarding the information contained in this update, contact the applicable Health Net Provider Services Center at:
Line of business | Phone number | Email address |
|---|---|---|
Health Net Employer Group HMO, POS, HSP, PPO, & EPO | 800-641-7761 | provider_services@healthnet.com |
Medicare (Individual & Employer Group) | 800-929-9224 | provider_services@healthnet.com |
Medi-Cal | 800-675-6110 | N/A |
1Resources available from the 2022 CPT® Professional Edition published by American Medical Association and ICD- 10-CM Expert for Physicians published by Optum360®.
This information applies to Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.
For Medi-Cal, this information applies to Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.