The following codes are thought to be relevant to Gastroenterology procedures and are referenced throughout this guide.

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2 THIS PROCEDURAL REIMBURSEMENT GUIDE, FOR SELECT GASTROENTEROLOGY PROCEDURES, provides coding and reimbursement information for physicians and facilities. The Medicare payment amounts shown are national average payments. Actual reimbursement will vary for each provider and institution based on geographic differences in costs, hospital teaching status, and proportion of low-income patients. Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding, or site of service requirements. The coding options listed within this guide are commonly used codes and are not intended to be an all-inclusive list. We recommend consulting your relevant manuals for appropriate coding options. The following codes are thought to be relevant to Gastroenterology procedures and are referenced throughout this guide. DESCRIPTION OF PAYMENT METHODS PHYSICIAN BILLING AND PAYMENT: Medicare and most other insurers typically reimburse physicians based on fee schedules tied to CPT CODES. CPT Codes are published by the American Medical Association and are used to report medical services and procedures performed by or under the direction of physicians. HOSPITAL OUTPATIENT BILLING AND PAYMENT: Medicare reimburses hospitals for outpatient stays (typically stays of less than 24 hours) under AMBULATORY PAYMENT CLASSIFICATION GROUPS (APCs). Medicare assigns a procedure to an APC based on the billed CPT Code. Hospitals may receive separate APC payments for each procedure done during the same outpatient visit. Many APCs are subject to reduced payment when multiple procedures are performed on the same day. In most cases, the highest valued procedure is paid at 100% and all other procedures are subject to a 50% payment reduction. In 2014, CMS implemented their COMPREHENSIVE APCs (C-APCs) policy with the goal of identifying certain high-cost devicerelated outpatient procedures (formerly device intensive APCs). CMS has fully implemented this policy and has identified these high-cost, device-related services as the primary service on a claim. All other services reported on the same date will be considered adjunctive, supportive, related or dependent services provided to support the delivery of the primary service and will be unconditionally packaged into the OPPS C-APC payment of the primary service with minor exceptions. Only select gastroenterology APCs are impacted. Procedures that are impacted are flagged ( ) throughout the guide. HOSPITAL INPATIENT BILLING AND PAYMENT: Medicare reimburses hospital inpatient procedures based on the MEDICARE SEVERITY DIAGNOSIS RELATED GROUP (MS-DRG). The MS-DRG is a system of classifying patients based on their diagnoses and the procedures performed during their hospital stay. MS-DRGs closely calibrate payment to the severity of a patient s illness. One single MS-DRG payment is intended to cover all hospital costs associated with treating an individual during his or her hospital stay, with the exception of professional (e.g., physician charges associated with performing medical procedures). Private payers may also use MS-DRG based systems or other payer-specific systems to pay hospitals for providing inpatient services. Effective October 1, 2013, Medicare implemented two-midnight stay guidance. Inpatient admittance is presumed to be appropriate if a physician expects a beneficiary s surgical procedure, diagnostic test or other treatment to require a stay in the hospital lasting at least two midnights, and admits the beneficiary to the hospital based on that expectation. Documentation in the medical record must support a reasonable expectation of the need for the beneficiary to require a medically necessary stay lasting at least two midnights. If the inpatient admission lasts fewer than two midnights due to an unforeseen circumstance this also must be clearly documented in the medical record. CPT copyright 2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. ENDO AB 2

3 FREE-STANDING CLINIC/AMBULATORY SURGICAL CENTER BILLING AND PAYMENT: Many procedures are performed outside of the hospital in free-standing clinics. Payments made to free-standing clinics from private insurers depend on the contract the clinic has with the payer. Medicare payments to free-standing clinics are determined in part, by the licensing status of the clinic. If a free-standing clinic is licensed by Medicare as an AMBULATORY SURGICAL CENTER (ASC) it is eligible to be reimbursed for select procedures provided in this setting. Not all procedures that Medicare covers in the hospital setting are eligible for payment in ASCs. Medicare has approved over 3,900 procedures (as defined by CPT Code), for which it will pay the ASC a facility fee. THIS GUIDE, FOR SELECT GASTROENTEROLOGY PROCEDURES, PROVIDES CODING AND REIMBURSEMENT INFORMATION FOR PHYSICIANS AND FACILITIES. THE CODES INCLUDED IN THIS GUIDE ARE INTENDED TO REPRESENT TYPICAL ENDOSCOPY PROCEDURES WHERE THERE IS: 1) At least one device approved or cleared by the U.S. Food and Drug Administration (FDA) for use in the listed procedure; and 2) Specific procedural coding guidance provided by a recognized coding or reimbursement authority such as the American Medical Association (AMA) or The Centers for Medicare and Medicaid Services (CMS). This guide is in no way intended to promote the off label use of medical devices. THE MEDICARE REIMBURSEMENT AMOUNTS SHOWN ARE CURRENTLY PUBLISHED NATIONAL AVERAGE PAYMENTS. Actual reimbursement will vary for each provider and institution for a variety of reasons including geographic difference in labor and non-labor costs, hospital teaching status, and/or proportion of low-income patients. On average, private payers pay more than Medicare. 7 Please feel free to contact the Boston Scientific Endoscopy Reimbursement Help Desk at or at ENDOreimbursement@bsci.com if you have any questions. You can find reimbursement updates on our website: Please note: this coding information may include codes for procedures for which Boston Scientific currently offers no cleared or approved products. In those instances, such codes have been included solely in the interest of providing users with comprehensive coding information and are not intended to promote the use of any Boston Scientific products for which they are not cleared or approved. The Health Care Provider (HCP) is solely responsible for selecting the site of service and treatment modalities appropriate for the patient based on medically appropriate needs of that patient and the independent medical judgement of the HCP. Health economic and reimbursement information provided by Boston Scientific Corporation is gathered from thirdparty sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules, and policies. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice. Boston Scientific encourages providers to submit accurate and appropriate claims for services. It is always the provider s responsibility to determine medical necessity, the proper site for delivery of any services, and to submit appropriate codes, charges, and modifiers for services rendered. It is also always the provider s responsibility to understand and comply with Medicare national coverage determinations (NCD), Medicare local coverage determinations (LCD), and any other coverage requirements established by relevant payers which can be updated frequently. Boston Scientific recommends that you consult with your payers, reimbursement specialists, and/or legal counsel regarding coding, coverage, and reimbursement matters. Boston Scientific does not promote the use of its products outside their FDA-approved label. Information included herein is current as of November 2018 but is subject to change without notice. Rates for services are effective January 1, ENDO AB 3

4 Biliary Procedural Reimbursement Guide All rates shown are 2019 Medicare national averages; actual rates will vary geographically and/or by individual facility. Medicare Physician, Hospital Outpatient, and ASC Payments CPT Code 1 Code Description Work Office Facility 2019 Medicare National Average Payment RVUs Physician,2 Facility 3 In-Office In-Facility Hospital Outpatient ASC Diagnostic Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) Therapeutic Endoscopic retrograde cholangiopancreatography (ERCP); with biopsy, single or multiple Endoscopic retrograde cholangiopancreatography (ERCP); with sphincterotomy/papillotomy Endoscopic retrograde cholangiopancreatography (ERCP); with pressure measurement of sphincter of Oddi Endoscopic retrograde cholangiopancreatography (ERCP); with removal of calculi/debris from biliary/pancreatic duct(s) Endoscopic retrograde cholangiopancreatography (ERCP); with destruction of calculi, any method (eg, mechanical, electrohydraulic, lithotripsy) Endoscopic retrograde cholangiopancreatography (ERCP); with transendoscopic balloon dilation of biliary/pancreatic duct(s) or of ampulla (sphincteroplasty), including sphincterotomy, when performed, each duct Endoscopic retrograde cholangiopancreatography (ERCP); with ablation of tumor(s), polyp(s), or other lesion(s), including pre- and post-dilation and guide wire passage, when performed Stenting Endoscopic retrograde cholangiopancreatography (ERCP); with placement of endoscopic stent into biliary or pancreatic duct, including pre- and postdilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent Endoscopic retrograde cholangiopancreatography (ERCP); with removal of foreign body(s) or stent(s) from biliary/pancreatic duct(s) Endoscopic retrograde cholangiopancreatography (ERCP); with removal and exchange of stent(s), biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent exchanged 5.85 NA 9.45 NA $341 $2,825 $1, NA 9.92 NA $358 $2,825 $1, NA NA $377 $2,825 $1, NA NA $377 $2,825 $1, NA NA $384 $2,825 $1, NA NA $457 $4,496 $1, NA NA $400 $2,825 $1, NA NA $457 $2,825 $1, NA NA $489 $4,496 $1, NA NA $398 $2,825 $1, NA NA $509 $4,496 $1,929 Medicare Hospital Inpatient Coding - Select Procedures ICD 10 PCS Code BF110ZZ BF111ZZ BF11YZZ 0FJB8ZZ 0FJD8ZZ BF100ZZ BF101ZZ BF10YZZ BF000ZZ BF001ZZ BF00YZZ BF000ZZ BF001ZZ BF00YZZ BF001ZZ BF00YZZ ICD 10 PCS Description Fluoroscopy of Biliary and Pancreatic Ducts using High Osmolar Contrast Fluoroscopy of Biliary and Pancreatic Ducts using Low Osmolar Contrast Fluoroscopy of Biliary and Pancreatic Ducts using Other Contrast Inspection of Hepatobiliary Duct, Via Natural or Artificial Opening Endoscopic Inspection of Pancreatic Duct, Via Natural or Artificial Opening Endoscopic Fluoroscopy of Bile Ducts using High Osmolar Contrast Fluoroscopy of Bile Ducts using Low Osmolar Contrast Fluoroscopy of Bile Ducts using Other Contrast Plain Radiography of Bile Ducts using High Osmolar Contrast Plain Radiography of Bile Ducts using Low Osmolar Contrast Plain Radiography of Bile Ducts using Other Contrast Plain Radiography of Bile Ducts using High Osmolar Contrast Plain Radiography of Bile Ducts using Low Osmolar Contrast Plain Radiography of Bile Ducts using Other Contrast Plain Radiography of Bile Ducts using Low Osmolar Contrast Plain Radiography of Bile Ducts using Other Contrast See important information about the uses and limitations of this document on pages 2 and 3 ENDO AB 4

5 Biliary Procedural Reimbursement Guide (Continued) Medicare Hospital Inpatient Coding - Select Procedures ICD 10 PCS Code 0F957ZX 0F958ZX 0F967ZX 0F968ZX 0F987ZX 0F988ZX 0F997ZX 0F998ZX 0F9C7ZX 0F9C8ZX 0FB57ZX 0FB58ZX 0FB67ZX 0FB68ZX 0FB87ZX 0FB88ZX 0FB97ZX 0FB98ZX 0FBC7ZX 0FBC8ZX 0F558ZZ 0F758DZ 0F758ZZ 0F568ZZ 0F768DZ 0F768ZZ 0F578ZZ 0F958ZZ 0F9580Z 0F968ZZ 0F9680Z 0FB58ZZ 0FB68ZZ 0FF58ZZ 0FF68ZZ 0FL58ZZ 0FL58DZ 0FL68ZZ 0FL68DZ 0FN58ZZ 0FN68ZZ 0FQ58ZZ 0FQ68ZZ 0FT58ZZ 0FT68ZZ 0FV58ZZ 0FV58DZ 0FV68ZZ 0FV68DZ 0F598ZZ 0F798DZ ICD 10 PCS Description Drainage of Right Hepatic Duct, Via Natural or Artificial Opening, Diagnostic Drainage of Right Hepatic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic Drainage of Left Hepatic Duct, Via Natural or Artificial Opening, Diagnostic Drainage of Left Hepatic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic Drainage of Cystic Duct, Via Natural or Artificial Opening, Diagnostic Drainage of Cystic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic Drainage of Common Bile Duct, Via Natural or Artificial Opening, Diagnostic Drainage of Common Bile Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic Drainage of Ampulla of Vater, Via Natural or Artificial Opening, Diagnostic Drainage of Ampulla of Vater, Via Natural or Artificial Opening Endoscopic, Diagnostic Excision of Right Hepatic Duct, Via Natural or Artificial Opening, Diagnostic Excision of Right Hepatic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic Excision of Left Hepatic Duct, Via Natural or Artificial Opening, Diagnostic Excision of Left Hepatic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic Excision of Cystic Duct, Via Natural or Artificial Opening, Diagnostic Excision of Cystic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic Excision of Common Bile Duct, Via Natural or Artificial Opening, Diagnostic Excision of Common Bile Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic Excision of Ampulla of Vater, Via Natural or Artificial Opening, Diagnostic Excision of Ampulla of Vater, Via Natural or Artificial Opening Endoscopic, Diagnostic Destruction of Right Hepatic Duct, Via Natural or Artificial Opening Endoscopic Dilation of Right Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Dilation of Right Hepatic Duct, Via Natural or Artificial Opening Endoscopic Destruction of Left Hepatic Duct, Via Natural or Artificial Opening Endoscopic Dilation of Left Hepatic Duct with Intraluminal Device, Endoscopic Dilation of Left Hepatic Duct, Endoscopic Destruction of Common Hepatic Duct, Via Natural or Artificial Opening Endoscopic Drainage of Right Hepatic Duct, Endoscopic Drainage of Right Hepatic Duct with Drainage Device, Endoscopic Drainage of Left Hepatic Duct, Endoscopic Drainage of Left Hepatic Duct with Drainage Device, Endoscopic Excision of Right Hepatic Duct, Endoscopic Excision of Left Hepatic Duct, Endoscopic Fragmentation in Right Hepatic Duct, Endoscopic Fragmentation in Left Hepatic Duct, Endoscopic Occlusion of Right Hepatic Duct, Endoscopic Occlusion of Right Hepatic Duct with Intraluminal Device Endoscopic Occlusion of Left Hepatic Duct, Endoscopic Occlusion of Left Hepatic Duct with Intraluminal Device, Endoscopic Release Right Hepatic Duct, Endoscopic Release Left Hepatic Duct, Endoscopic Repair Right Hepatic Duct, Endoscopic Repair Left Hepatic Duct, Endoscopic Resection of Right Hepatic Duct, Endoscopic Resection of Left Hepatic Duct, Endoscopic Restriction of Right Hepatic Duct, Endoscopic Restriction of Right Hepatic Duct with Intraluminal Device, Endoscopic Restriction of Left Hepatic Duct, Endoscopic Restriction of Left Hepatic Duct with Intraluminal Device, Endoscopic Destruction of Common Bile Duct, Endoscopic Dilation of Common Bile Duct with Intraluminal Device, Endoscopic See important information about the uses and limitations of this document on pages 2 and 3 ENDO AB 5

6 Biliary Procedural Reimbursement Guide (Continued) Medicare Hospital Inpatient Coding - Select Procedures ICD 10 PCS Code 0F798ZZ 0F998ZZ 0FB98ZZ 0FC98ZZ 0FF98ZZ 0FL98ZZ 0FL98DZ 0FT98ZZ 0FV98ZZ 0FV98DZ 0FN98ZZ 0FQ98ZZ 0F788DZ 0F788ZZ 0F5D8ZZ 0F7D8ZZ 0F7F8DZ 0F7F8ZZ 0F9D8ZX 0F9D8ZZ 0FBD8ZX 0FBD8ZZ 0FFD8ZZ 0FLD8ZZ 0FNF8ZZ 0FQF8ZZ 0FTD8ZZ 0FVD8ZZ 0FVF8DZ 0FPD80Z 0FPD81Z 0FPD82Z 0FPD83Z 0FPD87Z 0FPD8CZ 0FPD8DZ 0FPD8JZ 0FPD8KZ 0FPD8YZ 0FWD80Z 0FWD82Z 0FWD83Z 0FWD8CZ 0FWD8DZ 0FWD8JZ 0FHD8DZ 0FND8ZZ 0FQD8ZZ 0FNC8ZZ ICD 10 PCS Description Dilation of Common Bile Duct, Endoscopic Drainage of Common Bile Duct, Endoscopic Excision of Common Bile Duct, Endoscopic Extirpation of Matter from Common Bile Duct, Endoscopic Fragmentation in Common Bile Duct, Endoscopic Occlusion of Common Bile Duct, Endoscopic Occlusion of Common Bile Duct with Intraluminal Device, Endoscopic Resection of Common Bile Duct, Endoscopic Restriction of Common Bile Duct, Endoscopic Restriction of Common Bile Duct with Intraluminal Device, Endoscopic Release Common Bile Duct, Endoscopic Repair Common Bile Duct, Endoscopic Dilation of Cystic Duct with Intraluminal Device, Endoscopic Dilation of Cystic Duct, Endoscopic Destruction of Pancreatic Duct, Endoscopic Dilation of Pancreatic Duct, Endoscopic Dilation of Access Pancreatic Duct with Intraluminal Device, Endoscopic Dilation of Accessory Pancreatic Duct, Endoscopic Drainage of Pancreatic Duct, Endoscopic, Diagnostic Drainage of Pancreatic Duct, Endoscopic Excision of Pancreatic Duct, Endoscopic, Diagnostic Excision of Pancreatic Duct, Endoscopic Fragmentation in Pancreatic Duct, Endoscopic Occlusion of Pancreatic Duct, Endoscopic Release Accessory Pancreatic Duct, Endoscopic Repair Accessory Pancreatic Duct, Endoscopic Resection of Pancreatic Duct, Endoscopic Restriction of Pancreatic Duct, Endoscopic Restriction of Access Pancreatic Duct with Intraluminal Device, Endoscopic Removal of Drainage Device from Pancreatic Duct, Endoscopic Removal of Radioactive Element from Pancreatic Duct, Endoscopic Removal of Monitoring Device from Pancreatic Duct, Endoscopic Removal of Infusion Device from Pancreatic Duct, Endoscopic Removal of Autologous Tissue Substitute from Pancreatic Duct, Endoscopic Removal of Extraluminal Device from Pancreatic Duct, Endoscopic Removal of Intraluminal Device from Pancreatic Duct, Endoscopic Removal of Synthetic Substitute from Pancreatic Duct, Endoscopic Removal of Nonautologous Tissue Substitute from Pancreatic Duct, Endoscopic Removal of Other Device from Pancreatic Duct, Endoscopic Revision of Drainage Device in Pancreatic Duct, Endoscopic Revision of Monitoring Device in Pancreatic Duct, Endoscopic Revision of Infusion Device in Pancreatic Duct, Endoscopic Revision of Extraluminal Device in Pancreatic Duct, Endoscopic Revision of Intraluminal Device in Pancreatic Duct, Endoscopic Revision of Synthetic Substitute in Pancreatic Duct, Endoscopic Insertion of Intraluminal Device into Pancreatic Duct, Endoscopic Release Pancreatic Duct, Endoscopic Repair Pancreatic Duct, Endoscopic Release Ampulla of Vater, Endoscopic See important information about the uses and limitations of this document on pages 2 and 3 ENDO AB 6

7 Biliary Procedural Reimbursement Guide (Continued) Medicare Hospital Inpatient Coding - Select Procedures ICD 10 PCS Code 0FQC8ZZ 0F5C8ZZ 0F7C8DZ 0F7C8ZZ 0F9C80Z 0F9C8ZZ 0FBC8ZZ 0FFC8ZZ 0FLC8DZ 0FLC8ZZ 0FTC8ZZ 0FVC8DZ 0FVC8ZZ 0FCC8ZZ ICD 10 PCS Description Repair Ampulla of Vater, Endoscopic Destruction of Ampulla of Vater, Endoscopic Dilation of Ampulla of Vater with Intraluminal Device, Endoscopic Dilation of Ampulla of Vater, Endoscopic Drainage of Ampulla of Vater with Drainage Device, Endoscopic Drainage of Ampulla of Vater, Endoscopic Excision of Ampulla of Vater, Endoscopic Fragmentation in Ampulla of Vater, Endoscopic Occlusion of Ampulla of Vater with Intraluminal Device, Endoscopic Occlusion of Ampulla of Vater, Endoscopic Resection of Ampulla of Vater, Endoscopic Restriction of Ampulla of Vater with Intraluminal Device, Endoscopic Restriction of Ampulla of Vater, Endoscopic Extirpation of Matter from Ampulla of Vater, Endoscopic Medicare Hospital Inpatient Payment MS-DRG assignment is based on a combination of diagnoses and procedure codes reported. While MS-DRGs listed in this guide represent likely assignments, Boston Scientific cannot guarantee assignment to any one specific MS-DRG. MS-DRG Description Hospital Inpatient Medicare National Average Payment Malignancy of hepatobiliary system or pancreas with Major Complication or Comorbidity (MCC 5 ) $10, Malignancy of hepatobiliary system or pancreas with Complication or Comorbidity (CC 5 ) $6, Malignancy of hepatobiliary system or pancreas without CC/MCC $5, Disorders of pancreas except malignancy with MCC 5 $10, Disorders of pancreas except malignancy with CC 5 $5, Disorders of pancreas except malignancy without CC/MCC $3, Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis with MCC 5 $11, Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis with CC 5 $5, Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis without CC/MCC $4, Disorders of the biliary tract with MCC 5 $9, Disorders of the biliary tract with CC 5 $6, Disorders of the biliary tract without CC/MCC $4,854 See important information about the uses and limitations of this document on pages 2 and 3 ENDO AB 7

8 Biopsy Procedural Reimbursement Guide All rates shown are 2019 Medicare national averages; actual rates will vary geographically and/or by individual facility. Medicare Physician, Hospital Outpatient, and ASC Payments CPT Code 1 Code Description Work Office Cold Biopsy Facility In-Office In-Facility Hospital Outpatient Esophagoscopy, rigid, transoral; with biopsy, single or multiple 2.79 NA 4.88 NA $176 $1,483 $ Esophagoscopy, flexible, transoral; with biopsy, single or multiple $330 $108 $1,483 $ Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple Endoscopic retrograde cholangiopancreatography (ERCP); with biopsy, single or multiple Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with biopsy, single or multiple Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with biopsy, single or multiple $367 $146 $762 $ NA 9.92 NA $358 $2,825 $1, NA 4.65 NA $168 $1,483 $ NA 8.77 NA $316 $1,483 $ Ileoscopy, through stoma; with biopsy, single or multiple $281 $77 $762 $ Endoscopic evaluation of small intestinal pouch (eg, Kock pouch, ileal reservoir [S or J]); with biopsy, single or multiple $301 $94 $745 $ Colonoscopy through stoma; with biopsy, single or multiple $399 $181 $980 $ Proctosigmoidoscopy, rigid; with biopsy, single or multiple $158 $76 $980 $ Sigmoidoscopy, flexible; with biopsy, single or multiple $274 $75 $745 $ Colonoscopy, flexible; with biopsy, single or multiple $425 $212 $980 $505 Hot Biopsy Esophagoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps 2019 Medicare National Average Payment RVUs Physician,2 Facility $383 $139 $1,483 $ $425 $179 $1,483 $ NA 5.32 NA $192 $1,483 $ $369 $210 $980 $ $178 $88 $2,335 $1, $312 $98 $745 $ $473 $241 $980 $505 ASC Hospital Inpatient Coding and Medicare Payment Inpatient payment information not shown because the biopsy procedure will rarely, if ever, be the primary reason for a hospital admission. See important information about the uses and limitations of this document on pages 2 and 3 ENDO AB 8

9 Cholangioscopy Procedural Reimbursement Guide All rates shown are 2019 Medicare national averages; actual rates will vary geographically and/or by individual facility. Medicare Physician, Hospital Outpatient, and ASC Payments 2019 Medicare National Average Payment RVUs Physician,2 Facility 3 CPT Code 1 Code Description Work Office Cholangioscopy Endoscopic cannulation of papilla with direct visualization of pancreatic/common bile duct(s) (List separately in addition to code(s) for primary procedure* Facility In-Office In-Facility Hospital Outpatient 2.24 NA 3.49 NA $126 $0 $0 ASC CPT Code is an add-on code and must be reported with at least one of the following ERCP codes: Medicare Physician, Hospital Outpatient, and ASC Payments CPT Code 1 Code Description Work Office Diagnostic Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) Therapeutic Endoscopic retrograde cholangiopancreatography (ERCP); with biopsy, single or multiple Endoscopic retrograde cholangiopancreatography (ERCP); with sphincterotomy/papillotomy Endoscopic retrograde cholangiopancreatography (ERCP); with pressure measurement of sphincter of Oddi Endoscopic retrograde cholangiopancreatography (ERCP); with removal of calculi/debris from biliary/pancreatic duct(s) Endoscopic retrograde cholangiopancreatography (ERCP); with destruction of calculi, any method (eg, mechanical, electrohydraulic, lithotripsy) Endoscopic retrograde cholangiopancreatography (ERCP); with transendoscopic balloon dilation of biliary/pancreatic duct(s) or of ampulla (sphincteroplasty), including sphincterotomy, when performed, each duct Endoscopic retrograde cholangiopancreatography (ERCP); with ablation of tumor(s), polyp(s), or other lesion(s), including pre- and post-dilation and guide wire passage, when performed Stenting Endoscopic retrograde cholangiopancreatography (ERCP); with placement of endoscopic stent into biliary or pancreatic duct, including pre- and postdilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent Endoscopic retrograde cholangiopancreatography (ERCP); with removal of foreign body(s) or stent(s) from biliary/pancreatic duct(s) Endoscopic retrograde cholangiopancreatography (ERCP); with removal and exchange of stent(s), biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent exchanged RVUs Facility 2019 Medicare National Average Payment In-Office Physician,2 In-Facility Hospital Outpatient Facility NA 9.45 NA $341 $2,825 $1, NA 9.92 NA $358 $2,825 $1, NA NA $377 $2,825 $1, NA NA $377 $2,825 $1, NA NA $384 $2,825 $1, NA NA $457 $4,496 $1, NA NA $400 $2,825 $1, NA NA $457 $2,825 $1, NA NA $489 $4,496 $1, NA NA $398 $2,825 $1, NA NA $509 $4,496 $1,929 ASC See important information about the uses and limitations of this document on pages 2 and 3 ENDO AB 9

10 Cholangioscopy Procedural Reimbursement Guide (Continued) Medicare Hospital Inpatient Coding - Select Procedures ICD 10 PCS Code BF110ZZ BF111ZZ BF11YZZ 0FJB8ZZ 0FJD8ZZ BF100ZZ BF101ZZ BF10YZZ BF000ZZ BF001ZZ BF00YZZ 0F957ZX 0F958ZX 0F967ZX 0F968ZX 0F987ZX 0F988ZX 0F997ZX 0F998ZX 0F9C7ZX 0F9C8ZX 0FB57ZX 0FB58ZX 0FB67ZX 0FB68ZX 0FB87ZX 0FB88ZX 0FB97ZX 0FB98ZX 0FBC7ZX 0FBC8ZX 0F558ZZ 0F758DZ 0F758ZZ 0F568ZZ 0F768DZ 0F768ZZ 0F578ZZ 0F958ZZ 0F9580Z 0F968ZZ 0F9680Z 0FB58ZZ 0FB68ZZ ICD 10 PCS Description Fluoroscopy of Biliary and Pancreatic Ducts using High Osmolar Contrast Fluoroscopy of Biliary and Pancreatic Ducts using Low Osmolar Contrast Fluoroscopy of Biliary and Pancreatic Ducts using Other Contrast Inspection of Hepatobiliary Duct, Via Natural or Artificial Opening Endoscopic Inspection of Pancreatic Duct, Via Natural or Artificial Opening Endoscopic Fluoroscopy of Bile Ducts using High Osmolar Contrast Fluoroscopy of Bile Ducts using Low Osmolar Contrast Fluoroscopy of Bile Ducts using Other Contrast Plain Radiography of Bile Ducts using High Osmolar Contrast Plain Radiography of Bile Ducts using Low Osmolar Contrast Plain Radiography of Bile Ducts using Other Contrast Drainage of Right Hepatic Duct, Via Natural or Artificial Opening, Diagnostic Drainage of Right Hepatic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic Drainage of Left Hepatic Duct, Via Natural or Artificial Opening, Diagnostic Drainage of Left Hepatic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic Drainage of Cystic Duct, Via Natural or Artificial Opening, Diagnostic Drainage of Cystic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic Drainage of Common Bile Duct, Via Natural or Artificial Opening, Diagnostic Drainage of Common Bile Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic Drainage of Ampulla of Vater, Via Natural or Artificial Opening, Diagnostic Drainage of Ampulla of Vater, Via Natural or Artificial Opening Endoscopic, Diagnostic Excision of Right Hepatic Duct, Via Natural or Artificial Opening, Diagnostic Excision of Right Hepatic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic Excision of Left Hepatic Duct, Via Natural or Artificial Opening, Diagnostic Excision of Left Hepatic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic Excision of Cystic Duct, Via Natural or Artificial Opening, Diagnostic Excision of Cystic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic Excision of Common Bile Duct, Via Natural or Artificial Opening, Diagnostic Excision of Common Bile Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic Excision of Ampulla of Vater, Via Natural or Artificial Opening, Diagnostic Excision of Ampulla of Vater, Via Natural or Artificial Opening Endoscopic, Diagnostic Destruction of Right Hepatic Duct, Via Natural or Artificial Opening Endoscopic Dilation of Right Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Dilation of Right Hepatic Duct, Via Natural or Artificial Opening Endoscopic Destruction of Left Hepatic Duct, Via Natural or Artificial Opening Endoscopic Dilation of Left Hepatic Duct with Intraluminal Device, Endoscopic Dilation of Left Hepatic Duct, Endoscopic Destruction of Common Hepatic Duct, Via Natural or Artificial Opening Endoscopic Drainage of Right Hepatic Duct, Endoscopic Drainage of Right Hepatic Duct with Drainage Device, Endoscopic Drainage of Left Hepatic Duct, Endoscopic Drainage of Left Hepatic Duct with Drainage Device, Endoscopic Excision of Right Hepatic Duct, Endoscopic Excision of Left Hepatic Duct, Endoscopic See important information about the uses and limitations of this document on pages 2 and 3 ENDO AB 10

11 Cholangioscopy Procedural Reimbursement Guide (Continued) Medicare Hospital Inpatient Coding - Select Procedures ICD 10 PCS Code 0FF58ZZ 0FF68ZZ 0FL58ZZ 0FL58DZ 0FL68ZZ 0FL68DZ 0FN58ZZ 0FN68ZZ 0FQ58ZZ 0FQ68ZZ 0FT58ZZ 0FT68ZZ 0FV58ZZ 0FV58DZ 0FV68ZZ 0FV68DZ 0F598ZZ 0F798DZ 0F798ZZ 0F998ZZ 0FB98ZZ 0FC98ZZ 0FF98ZZ 0FL98ZZ 0FL98DZ 0FT98ZZ 0FV98ZZ 0FV98DZ 0FN98ZZ 0FQ98ZZ 0F788DZ 0F788ZZ 0F5D8ZZ 0F7D8DZ 0F7D8ZZ 0F7F8DZ 0F7F8ZZ 0F9D8ZX 0F9D8ZZ 0FBD8ZX 0FBD8ZZ 0FFD8ZZ 0FLD8ZZ 0FNF8ZZ ICD 10 PCS Description Fragmentation in Right Hepatic Duct, Endoscopic Fragmentation in Left Hepatic Duct, Endoscopic Occlusion of Right Hepatic Duct, Endoscopic Occlusion of Right Hepatic Duct with Intraluminal Device Endoscopic Occlusion of Left Hepatic Duct, Endoscopic Occlusion of Left Hepatic Duct with Intraluminal Device, Endoscopic Release Right Hepatic Duct, Endoscopic Release Left Hepatic Duct, Endoscopic Repair Right Hepatic Duct, Endoscopic Repair Left Hepatic Duct, Endoscopic Resection of Right Hepatic Duct, Endoscopic Resection of Left Hepatic Duct, Endoscopic Restriction of Right Hepatic Duct, Endoscopic Restriction of Right Hepatic Duct with Intraluminal Device, Endoscopic Restriction of Left Hepatic Duct, Endoscopic Restriction of Left Hepatic Duct with Intraluminal Device, Endoscopic Destruction of Common Bile Duct, Endoscopic Dilation of Common Bile Duct with Intraluminal Device, Endoscopic Dilation of Common Bile Duct, Endoscopic Drainage of Common Bile Duct, Endoscopic Excision of Common Bile Duct, Endoscopic Extirpation of Matter from Common Bile Duct, Endoscopic Fragmentation in Common Bile Duct, Endoscopic Occlusion of Common Bile Duct, Endoscopic Occlusion of Common Bile Duct with Intraluminal Device, Endoscopic Resection of Common Bile Duct, Endoscopic Restriction of Common Bile Duct, Endoscopic Restriction of Common Bile Duct with Intraluminal Device, Endoscopic Release Common Bile Duct, Endoscopic Repair Common Bile Duct, Endoscopic Dilation of Cystic Duct with Intraluminal Device, Endoscopic Dilation of Cystic Duct, Endoscopic Destruction of Pancreatic Duct, Endoscopic Dilation of Pancreatic Duct with Intraluminal Device, Endoscopic Dilation of Pancreatic Duct, Endoscopic Dilation of Access Pancreatic Duct with Intraluminal Device, Endoscopic Dilation of Accessory Pancreatic Duct, Endoscopic Drainage of Pancreatic Duct, Endoscopic, Diagnostic Drainage of Pancreatic Duct, Endoscopic Excision of Pancreatic Duct, Endoscopic, Diagnostic Excision of Pancreatic Duct, Endoscopic Fragmentation in Pancreatic Duct, Endoscopic Occlusion of Pancreatic Duct, Endoscopic Release Accessory Pancreatic Duct, Endoscopic See important information about the uses and limitations of this document on pages 2 and 3 ENDO AB 11

12 Cholangioscopy Procedural Reimbursement Guide (Continued) Medicare Hospital Inpatient Coding - Select Procedures ICD 10 PCS Code 0FQF8ZZ 0FTD8ZZ 0FVD8ZZ 0FVF8DZ 0FPD80Z 0FPD81Z 0FPD82Z 0FPD83Z 0FPD87Z 0FPD8CZ 0FPD8DZ 0FPD8JZ 0FPD8KZ 0FPD8YZ 0FWD80Z 0FWD82Z 0FWD83Z 0FWD8CZ 0FWD8DZ 0FWD8JZ 0FHD8DZ 0FND8ZZ 0FQD8ZZ 0FNC8ZZ 0FQC8ZZ 0F5C8ZZ 0F7C8DZ 0F7C8ZZ 0F9C80Z 0F9C8ZZ 0FBC8ZZ 0FFC8ZZ 0FLC8DZ 0FLC8ZZ 0FTC8ZZ 0FVC8DZ 0FVC8ZZ 0FCC8ZZ ICD 10 PCS Description Repair Accessory Pancreatic Duct, Endoscopic Resection of Pancreatic Duct, Endoscopic Restriction of Pancreatic Duct, Endoscopic Restriction of Access Pancreatic Duct with Intraluminal Device, Endoscopic Removal of Drainage Device from Pancreatic Duct, Endoscopic Removal of Radioactive Element from Pancreatic Duct, Endoscopic Removal of Monitoring Device from Pancreatic Duct, Endoscopic Removal of Infusion Device from Pancreatic Duct, Endoscopic Removal of Autologous Tissue Substitute from Pancreatic Duct, Endoscopic Removal of Extraluminal Device from Pancreatic Duct, Endoscopic Removal of Intraluminal Device from Pancreatic Duct, Endoscopic Removal of Synthetic Substitute from Pancreatic Duct, Endoscopic Removal of Nonautologous Tissue Substitute from Pancreatic Duct, Endoscopic Removal of Other Device from Pancreatic Duct, Endoscopic Revision of Drainage Device in Pancreatic Duct, Endoscopic Revision of Monitoring Device in Pancreatic Duct, Endoscopic Revision of Infusion Device in Pancreatic Duct, Endoscopic Revision of Extraluminal Device in Pancreatic Duct, Endoscopic Revision of Intraluminal Device in Pancreatic Duct, Endoscopic Revision of Synthetic Substitute in Pancreatic Duct, Endoscopic Insertion of Intraluminal Device into Pancreatic Duct, Endoscopic Release Pancreatic Duct, Endoscopic Repair Pancreatic Duct, Endoscopic Release Ampulla of Vater, Endoscopic Repair Ampulla of Vater, Endoscopic Destruction of Ampulla of Vater, Endoscopic Dilation of Ampulla of Vater with Intraluminal Device, Endoscopic Dilation of Ampulla of Vater, Endoscopic Drainage of Ampulla of Vater with Drainage Device, Endoscopic Drainage of Ampulla of Vater, Endoscopic Excision of Ampulla of Vater, Endoscopic Fragmentation in Ampulla of Vater, Endoscopic Occlusion of Ampulla of Vater with Intraluminal Device, Endoscopic Occlusion of Ampulla of Vater, Endoscopic Resection of Ampulla of Vater, Endoscopic Restriction of Ampulla of Vater with Intraluminal Device, Endoscopic Restriction of Ampulla of Vater, Endoscopic Extirpation of Matter from Ampulla of Vater, Endoscopic See important information about the uses and limitations of this document on pages 2 and 3 ENDO AB 12

13 Cholangioscopy Procedural Reimbursement Guide (Continued) Medicare Hospital Inpatient Payment MS-DRG assignment is based on a combination of diagnoses and procedure codes reported. While MS-DRGs listed in this guide represent likely assignments, Boston Scientific cannot guarantee assignment to any one specific MS-DRG. MS-DRG Description Hospital Inpatient Medicare National Average Payment Malignancy of hepatobiliary system or pancreas with Major Complication or Comorbidity (MCC 5 ) $10, Malignancy of hepatobiliary system or pancreas with Complication or Comorbidity (CC 5 ) $6, Malignancy of hepatobiliary system or pancreas without CC/MCC $5, Disorders of pancreas except malignancy with MCC 5 $10, Disorders of pancreas except malignancy with CC 5 $5, Disorders of pancreas except malignancy without CC/MCC $3, Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis with MCC 5 $11, Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis with CC 5 $5, Disorders of liver except malignancy, cirrhosis, alcoholic hepatitis without CC/MCC $4, Disorders of the biliary tract with MCC 5 $9, Disorders of the biliary tract with CC 5 $6, Disorders of the biliary tract without CC/MCC $4,854 See important information about the uses and limitations of this document on pages 2 and 3 ENDO AB 13

14 Dilation Procedural Reimbursement Guide All rates shown are 2019 Medicare national averages; actual rates will vary geographically and/or by individual facility. Medicare Physician, Hospital Outpatient, and ASC Payments CPT Code 1 Code Description Work Office Balloon Esophagoscopy, rigid, transoral; with balloon dilation (less than 30 mm diameter) Esophagoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed) Esophagoscopy, flexible, transoral; with transendoscopic balloon dilation (less than 30 mm diameter) Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed) Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter) Facility In-Office In-Facility Hospital Outpatient 3.07 NA 5.32 NA $192 $2,825 $1, NA 5.61 NA $202 $1,483 $ $1,066 $124 $1,483 $ NA 6.68 NA $241 $1,483 $ $1,081 $162 $1,483 $ Ileoscopy, through stoma; with transendoscopic balloon dilation $976 $88 $1,483 $ Colonoscopy through stoma; with transendoscopic balloon dilation $561 $194 $980 $ Sigmoidoscopy, flexible; with transendoscopic balloon dilation $455 $81 $980 $ Colonoscopy, flexible; with transendoscopic balloon dilation $613 $223 $980 $505 Balloon or Rigid Esophagoscopy, rigid, transoral; with insertion of guide wire followed by dilation over guide wire Esophagoscopy, flexible, transoral; with dilation of esophagus, by balloon or dilator, retrograde (includes fluoroscopic guidance, when performed) Esophagoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) over guide wire Esophagogastroduodenoscopy, flexible, transoral; with dilation of gastric/ duodenal stricture(s) (eg, balloon, bougie) Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire 2019 Medicare National Average Payment RVUs Physician,2 Facility NA 5.67 NA $204 $2,825 $1, $1,220 $272 $1,483 $ $346 $137 $1,483 $ $585 $185 $1,483 $ $379 $175 $762 $ Proctosigmoidoscopy, rigid; with dilation (eg, balloon, guide wire, bougie) $949 $89 $980 $505 ASC Hospital Inpatient Coding and Medicare Payment Inpatient payment information not shown because the dilation procedure will rarely, if ever, be the primary reason for a hospital admission. See important information about the uses and limitations of this document on pages 2 and 3 ENDO AB 14

15 Endoscopic Submucosal Dissection Procedural Reimbursement Guide All rates shown are 2019 Medicare national averages; actual rates will vary geographically and/or by individual facility. Medicare Physician, Hospital Outpatient, and ASC Payments 2019 Medicare National Average Payment RVUs Physician,2 Facility 3 CPT Code 1 Code Description Work Office Facility In-Office In-Facility Hospital Outpatient ASC ESD* Unlisted procedure, esophagus NA NA NA NA NA $762 N/A Unlisted procedure, stomach NA NA NA NA NA $762 N/A Unlisted procedure, small intestine NA NA NA NA NA $762 N/A Unlisted procedure, colon NA NA NA NA NA $745 N/A Unlisted procedure, rectum NA NA NA NA NA $745 N/A *Note: Currently, there are no unique Current Procedural Terminology (CPT) codes for ESD. In the absence of a unique ESD code, providers may bill an unlisted procedure code. Providers should submit a cover letter with the claim that explains the nature of the procedure, equipment required, estimated practice cost, and a comparison of physician work (time, intensity, risk) with other comparable services for which the payer has an established value. Reimbursement information is being provided for illustrative purposes only. Providers are solely responsible for all procedure, coding and billing decisions. See important information about the uses and limitations of this document on pages 2 and 3 ENDO AB 15

16 Endoscopic Ultrasound-Guided Procedural Reimbursement Guide Select Endoscopy Procedures All rates shown are 2019 Medicare national averages; actual rates will vary geographically and/or by individual facility. Medicare Physician, Hospital Outpatient, and ASC Payments 2019 Medicare National Average Payment RVUs Physician,2 Facility 3 CPT Code 1 Code Description Work Office Facility In-Office In-Facility Hospital Outpatient ASC Upper Gastrointestinal Procedures Esophagoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), (includes endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures) Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis) $429 $210 $1,483 $ NA 6.81 NA $245 $1,483 $ NA 7.69 NA $277 $1,483 $ Esophagogastroduodenoscopy, flexible, transoral; with optical endomicroscopy $323 $178 $2,825 $1, Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided transmural injection of diagnostic or therapeutic substance(s) (eg, anesthetic, neurolytic agent) or fiducial marker(s) (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis) Lower Gastrointestinal Procedures Colonoscopy through stoma; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) Colonoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures 4.73 NA 7.70 NA $278 $1,483 $ NA 8.08 NA $291 $980 $ NA 4.96 NA $179 $980 $ NA 8.91 NA $321 $980 $505 Hospital Inpatient Coding and Medicare Payment Inpatient payment information not shown because the endoscopic ultrasound-guided fine needle aspiration procedure will rarely, if ever, be the primary reason for a hospital admission. See important information about the uses and limitations of this document on pages 2 and 3 ENDO AB 16

17 Endoscopic Ultrasound-Guided Transluminal Drainage and Endoscopic Necrosectomy Procedures of Pancreatic Pseudocyst and Walled-Off Necrosis Procedural Reimbursement Guide All rates shown are 2019 Medicare national averages; actual rates will vary geographically and/or by individual facility. Medicare Physician, Hospital Outpatient, and ASC Payments 2019 Medicare National Average Payment RVUs Physician,2 Facility 3 CPT Code 1 Code Description Work Office Facility In-Office In-Facility Hospital Outpatient ASC Stent Placement Esophagogastroduodenoscopy, flexible, transoral; with transmural drainage of pseudocyst (includes placement of transmural drainage catheter[s]/stent[s], when performed, and endoscopic ultrasound, when performed) Stent Retrieval Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body(s) Endoscopic Necrosectomy 7.15 NA NA $414 $2,825 $1, $369 $187 $762 $ Unlisted procedure, pancreas NA NA NA NA NA $579 N/A *Note: Currently, there is no unique Current Procedural Terminology (CPT) code to describe endoscopic necrosectomy. In the absence of a unique code, providers should bill an unlisted procedure code. Providers should submit a cover letter to the payer with the claim that explains the nature of the procedure, equipment required, estimated practice cost, and a comparison of the physician work (time, intensity, risk) with other comparable services for which the payer has an established value. Medicare Hospital Inpatient Coding - Select Procedures ICD-10 PCS Code 0F9G80Z 0FBG8ZZ Description Drainage of Pancreas with Drainage Device, Via Natural or Artificial Opening Endoscopic Excision of Pancreas, Via Natural or Artificial Opening Endoscopic Medicare Hospital Inpatient Payment MS-DRG assignment is based on a combination of diagnoses and procedure codes reported. While MS-DRGs listed in this guide represent likely assignments, Boston Scientific cannot guarantee assignment to any one specific MS-DRG. MS-DRG Description Hospital Inpatient Medicare National Average Payment 405 Pancreas, liver and shunt procedures with MCC $32, Pancreas, liver and shunt procedures with CC $17, Pancreas, liver and shunt procedures without CC/MCC $12, Disorders of pancreas except malignancy with MCC $10, Disorders of pancreas except malignancy with CC $5, Disorders of pancreas except malignancy without CC/MCC $3,793 This coding information may include codes for procedures for which Boston Scientific currently offers no cleared or approved products. In those instances, such codes have been included solely in the interest of providing users with comprehensive coding information and are not intended to promote the use of any Boston Scientific products for procedures for which they are not cleared or approved. The Health Care Provider (HCP) is solely responsible for selecting the site of service and treatment modalities appropriate for that patient based on medical appropriate needs of that patient and the independent medical judgment of the HCP. MS-DRG assignment is based on a combination of diagnoses and procedure codes reported. While MS-DRGs listed in this guide represent likely assignments, Boston Scientific cannot guarantee assignment to any one specific MS-DRG. See important information about the uses and limitations of this document on pages 2 and 3 ENDO AB 17

18 Enteral Feeding Procedural Reimbursement Guide All rates shown are 2019 Medicare national averages; actual rates will vary geographically and/or by individual facility. Medicare Physician, Hospital Outpatient, and ASC Payments CPT Code 1 Code Description Work Office Gastrostomy Tube Initial Placement Esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Gastrostomy Tube Replacement/Reposition Repositioning of a naso- or oro-gastric feeding tube, through the duodenum for enteric nutrition Facility In-Office In-Facility Hospital Outpatient 3.56 NA 5.86 NA $211 $1,483 $ $973 $215 $1,483 $ $124 $107 $231 $ Replacement of gastrostomy tube, with no revision $227 $39 $231 $ Replacement of gastrostomy tube, with evision $338 $87 $231 $ Replacement of gastrostomy or cecostomy (or other colonic) tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Jejunostomy Tube Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with conversion of percutaneous gastrostomy tube to percutaneous jejunostomy tube Insertion of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Conversion of gastrostomy tube to gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Replacement of gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Other Procedures Mechanical removal of obstructive material from gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, any method, under fluoroscopic guidance including contrast injection(s), if performed, image documentation and report 2019 Medicare National Average Payment RVUs Physician,2 Facility $678 $69 $762 $ NA 5.62 NA $203 $1,483 $ $1,104 $252 $1,483 $ $935 $155 $1,483 $ $907 $145 $762 $ $737 $50 $762 $392 ASC Hospital Inpatient Coding and Medicare Payment Inpatient payment information not shown because the enteral feeding procedure will rarely, if ever, be the primary reason for a hospital admission. See important information about the uses and limitations of this document on pages 2 and 3 ENDO AB 18