# india ink tattoo



## ilvchopin

How would you code EGD w bx and india ink tattoo in stomach area?  Would you use 43239 (EGD w BX?) and 43201 (EGD w submucosal injection, any substance?) with a modifier, either 59 or 51?  Or would you code the 43239 and an unlisted code such as 43999, unlisted proc, stomach? and a modifier? and send op notes?  Please help. Thanks.


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## flmoore

Your Dr. did an EGD and tat? I have never heard of a Dr. doing tat's on pt's


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## j.berkshire

The code for India ink marking (or tattooing) of a lesion is the submucosal injection code.  For EGD that code is 43236.  You would code the biopsy if it was on a separate lesion.  Codes would be billed as 43239, 43236-59.


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## Anna Weaver

*india ink*

I agree with Jenny, if it's a separate lesion 43239 and 43236-59. If it's the same lesion 43236 only.


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## TNavarre

*Marking w/India Ink*

Our physician has also performed procedures & used the India Ink tattooing.  The primary procedures performed were different: 44378,  another pt 45385 & next pt 44360.  On the 3rd pt. he also performed an UGI/43235 same encounter. (causing multiple procedure issue)  Our biller/coder used 11920 for the India Ink, listing procedure code first.  I disagreed.  Two insurance carriers denied as non covered cosmetic procedure/pt responsibility, even after appeal(s).  The third carrier paid a little over 105.00 for the procedure, with no pt responsibility.

I am inclined to want the tattooing billed using the correct procedure code w/a -59 modifier.  During the procedure, a lesion, etc. is identified & the doctor marks the area/ lesion, for the surgeon(s) to easily find & remove all of malignant area.  

I have not found any documentation, &/or information to make an argument as how to code it differently.  If anyone knows of how this is to be billed or where to find documentation, information or references of the billing for this type of procedure, it would be greatly appreciated!


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## j.berkshire

Thelma,  CPT Assistant and the AGA have an article called "Colonoscopy Coding Made Simple" which gives instructions for billing for interventions during colonoscopy.  It instructs to bill the submucosal injection code when the physician lifts a polyp with saline or "tattoos” an area with India ink for later identification during a subsequent procedure or during surgery.  These instructions can be applied to interventions in other endoscopies.  I would suggest getting a copy of this publication and keeping it as a reference to support billing using the submucosal injection code for tattooing a lesion.


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## Lisa Bledsoe

j.berkshire said:


> Thelma,  CPT Assistant and the AGA have an article called "Colonoscopy Coding Made Simple" which gives instructions for billing for interventions during colonoscopy.  It instructs to bill the submucosal injection code when the physician lifts a polyp with saline or "tattoos” an area with India ink for later identification during a subsequent procedure or during surgery.  These instructions can be applied to interventions in other endoscopies.  I would suggest getting a copy of this publication and keeping it as a reference to support billing using the submucosal injection code for tattooing a lesion.



ABSOLUTELY!!
Also, if the tatooing or submucosal injection is at the same site as a polyp or lesion removal, you should report 45381 with modifier -51.


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## Anna Weaver

*india ink*



TNavarre said:


> Our physician has also performed procedures & used the India Ink tattooing.  The primary procedures performed were different: 44378,  another pt 45385 & next pt 44360.  On the 3rd pt. he also performed an UGI/43235 same encounter. (causing multiple procedure issue)  Our biller/coder used 11920 for the India Ink, listing procedure code first.  I disagreed.  Two insurance carriers denied as non covered cosmetic procedure/pt responsibility, even after appeal(s).  The third carrier paid a little over 105.00 for the procedure, with no pt responsibility.
> 
> I am inclined to want the tattooing billed using the correct procedure code w/a -59 modifier.  During the procedure, a lesion, etc. is identified & the doctor marks the area/lesion, for the surgeon(s) to easily find & remove all of malignant area.
> 
> I have not found any documentation, &/or information to make an argument as how to code it differently.  If anyone knows of how this is to be billed or where to find documentation, information or references of the billing for this type of procedure, it would be greatly appreciated!



I would not use 11920. This is intradermal. The submucosal injection is what I would use. Here is what CPT assistant says!

  	Sigmoidoscopy with submucosal injection(s) 
	CPT Assistant, March 2003 Page: 22   Category: 
	Related Information
Surgery / Digestive System

Question:

For codes 45335, Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance, and 45381, Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance, would the injection of india ink qualify for the reporting of this code?

AMA Comment:

Yes. Prior to the addition of these codes in 2003, there were no codes in the CPT code set that adequately described the additional time, work involved, and risk to the patient of the submucosal injection, as typically, this is a more difficult and lengthy endoscopic procedure. The code descriptor for both codes is generic in stating "any substance" and is to be reported only once for each procedure regardless of the number of injections performed. Examples of a substance that may be injected includes India ink, which permits marking of a lesion allowing easier surgical or endoscopic identification of the involved segment of the gastrointestinal tract in the future. Other examples of submucosal injected substances are botulinum toxin, saline, and corticosteroid solutions.




CPT Assistant © Copyright 1990–2009 American Medical Association. All Rights Reserved


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## TNavarre

Thank you for your replies, I am going to find the CPT Assistant and the AGA article.  

I am up against a BRICK WALL when it comes to disputing the codes & procedures & they way the are billed.  It is frustrating not being able to just discuss a particular code & appropriate use.  It seems a though they are offended or take it as an insult.  I'm really not questioning their knowledge or trying to insult, only bill appropriately for services provided.  The biller becomes defensive & it has made it very hard for me to address these issues.  They close the door for communication by stating something to the effect I have been doing this for 25 years, I know what I'm doing, I'm right...  In most cases she refuses to hear me or even look at the CPT/HCPCs description in question!  Although, I leave the book(s) opened to the page where the code/description is on her desk.  I also have approximately the same # of years working but for mulitiple areas.  This is the first year working w/gastroenterologist & since procedures are performed mainly in the office perhaps I feel some codes are inclusive of the procedure that may be billable due to setting...  

I opened to suggestion & very willing to learn, including researching codes to try to determine the correct way to use & bill the procedure.


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## TNavarre

Thank you so much for the information!  I was able to print the referenced materials, learn how it should be billed & have billing corrected!  I searched for info on the code & the India Ink tattooing w/o locating.  The information is complete & describes exactly how to use/bill for services!


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