Distinguish ‘sample collection’ from actual biopsy.
When your gastroenterologist ventures into a patient’s stomach, say while treating gastroesophageal reflux disease (GERD), chances are she’d choose to evaluate the surface of the lower or distal esophagus. This service, known as esophagogastroduodenoscopy (EGD), mainly involves imaging the upper GI tract comprising the esophagus, stomach, and first part of the small intestine, also known as the duodenum.
You should keep your hopes high for a potential $345 payment by easily navigating through the finer points of EGD coding.
Here’s how: Take a look at this op note where a gastroenterologist carried out a conventional EGD with sedation, and find out.
Op note: Informed consent was got. The patient was carefully premedicated with a total of 5 mg of Versed intravenously given in careful titration prior to and during the procedure.
The adult fiberoptic gastroscope was passed into the esophagus under direct vision without complications. All areas were examined carefully. The esophagus seemed to appear normal. The GE junction was at about 40 cm.
Multiple four- quadrant biopsies were obtained. After this, the stomach was examined. There were superficial ulcerations of the consistent with NSAID ulcerations. Multiple biopsies were got. The body of the stomach was normal and retroflexion showed a normal cardia and fundus. Biopsies of the antrum and body of the stomach were got for CLO test to assess for H. pylori. The duodenal bulb was normal and the second portion of the duodenum was also normal. The patient tolerated the procedure well minus complications.
Remember the ‘Big 3’
First, while coding an upper GI endoscopy, see to it that you consider these factors:
How far your gastroenterologist went with the scope (example to the esophagus, stomach, or duodenum); If the doctor carried out any biopsies or polyp removal and what technique is used (that is cold biopsy, hot biopsy or snare) The kind of dilator used by your physician (if she performed dilation at all). In this situation, the op note clearly states that she examined the patient for signs of Barrett’s esophagus (530.85, Barrett’s esophagus), and took biopsies; examined the stomach, and took biopsies; before she finally examined the duodenum. Therefore, you should code the procedure with 43239. If the doctor examined the esophagus only, you’d select from the esophagus endoscopy code set 43200-43234.Revenue: if the procedure was carried out in the office, you should anticipate to collect $345.20 as national rate for your claim using 43239 (10.16 relative value units multiplied by the 2011 conversion factor of 33.9764). Code the primary diagnosis with 531.90 ( Gastric ulcer unspecified as acute or chronic without hemorrhage or perforation without obstruction). If you know from history what medicine the patient use, you may add V58.64 as secondary diagnosis.Do not discard biopsy, polyp treatment during EGD It is important that you’re aware of what your gastroenterologist did while carrying out the EGD on the patient. For example, with biopsies, remember that no matter how many biopsies a physician takes during the endoscopy, you can only code one procedure (43239 in this case). But then, an exception allows you to bill 43238 if the doctor also performed ultrasound guided aspiration on a separate anatomical site. Note of caution: Don’t mistake collection of samples from carrying out a biopsy. Doctors normally collect samples of fluid or superficial tissue cells during an EGD. This service is included in the base procedure 43235. On the other hand, doctors would carry out an EGD with biopsy of any abnormality straight through the endoscope of suspected Barrett’s esophagus or duodenal and stomach ulcers. Oftentimes, the doctor would treat polyps or other lesions during an EGD. You have three CPTs to select from for lesion removals:
43250 43251 43258 You can code one EGD with lesion removal but then if the doctor treats different lesions with different procedures, you could add modifier 59 (distinct procedural service) to the procedure of lesser value to break the bundle. For more on this and for other specialty-specific articles to assist your gastroenterology coding, sign up for a good medical coding resource like Coding Institute.