11.03.18, Endoscopic Submucosal Dissection (ESD)

By October 1, 2025: Billing team must implement the following: 1. Update billing system with ESD coverage criteria for all four indications (esophageal, gastric, colorectal). Configure system to flag claims for prior authorization review. 2. Create prior authorization checklist requiring providers to document: (a) lesion size and differentiation grade, (b) invasion depth with staging classification (AJCC, JES, NICE, JNET, or Kudo), (c) ulceration status, (d) low-risk lymph node metastasis assessment. 3. Map procedure codes to authorization requirements: - CPT 43499, 43999: For esophageal and gastric ESD claims - CPT 45399, 45999: For colorectal ESD claims - HCPCS C9779: Primary billing code for all ESD procedures 4. Train billing and prior authorization staff on lesion classification systems (Paris classification, Kudo pit pattern, NICE, JNET) to recognize compliant vs. non-compliant submissions. 5. Deny claims not meeting criteria as experimental/investigational with explanation referencing Policy 11.03.18. 6. Verify provider credentials: Only allow ESD billing from providers with documented training (minimum 1000 upper GI endoscopies or 500 colonoscopies per ASGE guidelines). Failure to implement will result in improper claim processing, denials, and potential recovery of overpayments.