Thursday, August 4, 2016

CPT CODE 43229 AND 43270

Argon Plasma Coagulation

Argon plasma coagulation: A non-contact thermal technique which uses ionized argon gas to deliver a high-frequency current which coagulates tissue.

CPT     43229    Esophagoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) [when specified as cryoablation, laser ablation, electrocoagulation or argon plasma coagulation]

43270    Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s), polyp(s) or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) [when specified as cryoablation, laser ablation, electrocoagulation or argon plasma coagulation]

Argon plasma coagulation involves the use of ionized argon gas to deliver a high-frequency current to destroy diseased tissue. In 2007, Mork and colleagues reported on 25 individuals who received argon plasma coagulation and a proton-pump inhibitor prior to and following the ablation procedure. The individuals received endoscopic surveillance every 3 months during the first year following complete eradication of the glandular epithelium. Follow-up was 51 months and recurrence of Barrett's esophagus was detected in 14 of the 25 individuals. Four individuals were lost during the study: 1 was excluded for compliance issues, 1 refused further argon plasma coagulation sessions and 2 others had only incomplete squamous restoration after 3 and 4 treatment sessions. One individual had relapse of Barrett's esophagus 3 times and was treated by argon plasma coagulation 11 times. This individual eventually had laparoscopic fundoplication. Seven individuals had no recurrence during the follow-up period. Seven individuals had the first recurrence of Barrett's esophagus detectable by microscope. Seven individuals had relapse detectable endoscopically and histologically during the same endoscopy. This study shows a relapse rate of approximately two-thirds after eradication of Barrett's esophagus after argon plasma coagulation. Success rates may be dependent on the thermic energy applied and the proton pump inhibitor schedule. Higher energy may carry more risks, but no standards have been established for this procedure yet.

Formentini (2007) reported on a retrospective analysis of the efficacy of ablation of Barrett's esophagus using argon plasma coagulation followed by fundoplication. Twenty-one individuals met study criteria and were the population. All individuals received argon plasma coagulation treatments approximately every 4-6 weeks until the metaplastic epithelium was completely ablated. Then all individuals underwent Nissen fundoplication. Response to treatment was measured with endoscopy every 6-12 months. Postoperatively 17 out of 21 participants had at least 1 endoscopic control. Recurrence of Barrett's esophagus was observed in 6 of the 17 participants. Five of the 6 participants had ablation by argon plasma coagulation (one participant refused) and were disease-free at the writing of this article. The authors acknowledge that "further studies are required to clarify the role of ablation's procedure in the treatment of BE."

Bright (2009) reported on a randomized controlled trial which compared 57 participants with Barrett's esophagus to undergo argon plasma coagulation or annual endoscopic surveillance. Another endoscopy was scheduled at 12 months for both groups of participants and biopsies were taken. The biopsies were examined by a pathologist who was unaware of the previous treatment (argon plasma coagulation or surveillance). At 12 months, 14 out of 23 participants who had received argon plasma coagulation showed at least 95% ablation of the metaplastic mucosa and 9 participants had complete regression of Barrett's esophagus. None of the individuals who had surveillance endoscopy had more than 95% regression. While these results look promising, ablation with argon plasma coagulation is more time-consuming than routine surveillance endoscopy, participants who have had argon plasma coagulation still need endoscopic surveillance and in this particular study, at least some of the metaplastic columnar mucosa recurred during the first 12 months. While the recurrences were small, it is not possible to predict which individuals will have recurrence and the outcomes at 12 months were not as good as immediately following the treatment. The authors have concluded that argon plasma coagulation "should probably remain within clinical trials."

Manner and colleagues (2014) reported on 63 participants who had been curatively resected of Barrett's neoplasia by endoscopy and were randomized to receive either argon plasma coagulation (n=33) or surveillance only (n=30). The primary outcome was recurrence-free survival. During the follow-up period of 2 years, in the ablation group 1 secondary lesion was found and 11 secondary lesions were found in the surveillance group. While the results showed fewer secondary lesions following argon plasma coagulation, this study was limited by its small group size and according to the authors a "limited follow-up of 2 years."

When services are also Investigational and Not Medically Necessary:

      
ICD-10 Procedure  
 
     For the following codes when specified as cryoablation, laser ablation, electrocoagulation or argon plasma coagulation:
0D514ZZ    Destruction of upper esophagus, percutaneous endoscopic approach
0D518ZZ    Destruction of upper esophagus, via natural or artificial opening endoscopic
0D524ZZ    Destruction of middle esophagus, percutaneous endoscopic approach
0D528ZZ    Destruction of middle esophagus, via natural or artificial opening endoscopic
0D534ZZ    Destruction of lower esophagus, percutaneous endoscopic approach
0D538ZZ    Destruction of lower esophagus, via natural or artificial opening endoscopic
0D544ZZ    Destruction of esophagogastric junction, percutaneous endoscopic approach
0D548ZZ    Destruction of esophagogastric junction, via natural or artificial opening endoscopic
0D554ZZ    Destruction of esophagus, percutaneous endoscopic approach
0D558ZZ    Destruction of esophagus, via natural or artificial opening endoscopic
      
ICD-10 Diagnosis     
K22.70-K22.719    Barrett's esophagus

Radiofrequency ablation may be considered medically necessary for treatment of Barrett’s esophagus with high-grade dysplasia. The diagnosis of high-grade dysplasia should be confirmed by two pathologists prior to radiofrequency ablation.

Radiofrequency ablation may be considered medically necessary for treatment of Barrett’s esophagus with low-grade dysplasia, when the initial diagnosis of low-grade dysplasia is confirmed by two pathologists, one of whom is an expert in GI Pathology. It is ideal that two experts in GI pathology agree on the diagnosis in order to confirm LGD.

Radiofrequency ablation is considered not medically necessary for treatment of Barrett’s esophagus in the absence of dysplasia due to lack of peer reviewed literature that supports efficacy. Cryoablation is considered not medically necessary for Barrett’s esophagus, with or without dysplasia due to lack of peer reviewed literature that supports efficacy.



There is no CPT code specific to radiofrequency or cryoablation of tissue in the esophagus. These procedures would likely be coded using one of the following CPT codes:

43229, 43257, 43270, 43499

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