# Esophagogastroduonenoscopy w/Nitinol Stent Placement



## TNavarre (Jul 24, 2009)

I am looking for a website &/or any other suggestions for finding detail description of cpt codes.  Currently it is for the EGD's w/multiple stent placement, removal & replacement.  The cpt book I currently have does not have enough details to determine proper code usage.  Please help...  

Procedures in detail:
6/21/09  Pt is in-pt, Critical Care Unit - Pre-op Post Gastric Bypass, rectal band gastropexy in past w continued obesity, then a revision of vertical gastric banding & converting it to a Roux-en-Y, subsequently internal hernia resulting in a blow out of the ananstomosis w/various drains were put toevacuate.  A hemostatic clip was placed about 5 cm downstream in the jejunum, another placed about 3 cm above the GE junction.  Scope withdrawn subsequently, & using fluoroscopy Alveolus Nitinol stent was placed over the guidewire into the jejunum.  By using the deploying devise, the jejunum coming into the gastric pouch.  Guidewire left in place.  Subsequently, a 2nd Alveolus Nitinol stent was introduced into esophagus and slowly advanced into the existing stent and deployed inside the existing stent.  The rest of the stent was deployed all the way up to the distal esophagus.  The scope was reintroduced & the stent was seen to be in excellent position.  An NG tube was introduced for decompression.

Chgs enter for above were 43256 x3, EGD w/deployment NOT billed.  Can't the deployment be billed separately from the 43256?  Where can I find more info on multiple stent placement &/or removal?

7-5-09 Pt still In-pt Critical Care Unit.  Post gastric bypass & subsequently developed a leak at the gasrojejunal anastomosis.  Procedure explained & consent obtained from pt's family.  Endoscope was passed into the pharynx guided into the esophagus and proximal edge of the previous stent was identified.  There was some space between the lip of the proximal stent & the wall of the esophagus.  The scope was passed through the stent all the way into jejunum & mucosa was carefully examined & there was some edema at the distal end of the stent.  A small ulceration was seen in the middle, which probably is from the NG sunction.  Using a catheter, Gastrografin was injected slightly distal to the distal end of the stent & no leakage was seen.  Dye was carefully injected in all 4 quadrants as the catheter was being pulled into the distal stent at the junction of both stents w/the scope as well as the proximal stent.  There was some leakage seen tracking around the upper lip of the proximal stent & leaking out.  So it was established that the leakage was not from the junction of the 2 stents but rather proximally.  A guidewire was placed through the stent into the jejunum & scope was withdrawn.  Over the guide wire, a third stent was placed, straddling exactly the edge of the proximal stent.  The stent was carefully deployed using fluoroscopy so that half of the stent is still scoped into the proximal stent and the other half is in the esophagus.  Optimal position of the stents were confirmed.  Carefully examined...  Monitor pt for any more leakage...  

Chgs entered for above were 43256 -22, x3, & 43236 -22.  Fluoroscopy billed by radiologist /hospital...

7-23-09 Pt remains In-pt Critical Care Unit. Procedure explained & consent obtained from pt's family.  Throat sprayed w/Cetacaine.  After adequate anthesthesia obtained, the scope was passed into the pharynx guided into esophagus, whereupon the proximal end of the proximal stent was seen.  Complete upper endoscopy was performed & stents seemed to be in good shape w/o deterioration.  By grasping the nylon filament at the proximal end of the proximal stent this was pushed to loosen it from the esophageal wall from overgrowth.  By applying steady traction the proximal stent was taken out.  The entire area was irrigated.  Scope was reintroduced & the middle stent was taken out using the same technique.  Subsequently, the distal end was also taken out.  Upon removing all three stents, careful examination of the anastomosis, revealed a fistulous opening at the gastrojejunum anastomosis.  Methylene blue was injected through this area & this was seen coming out of the wound VAC.  A subsequent dye injection also confirmed the same.  Upon deliberation & discussion it was decided to put a drain & not reinsert the stent(s).  Pt will be monitored for the quantity of leakage of fluid as well as the v/s to see if the pt is septic.  Pt tolerated procedure well.  -- Chgs entered 43247 -22 x3, 43236 -22.

Pt is still in hosp. repeat procedures include the above & gastroscopy w/Dobbhoff placement, etc.

Are the above billed correctly?  I can't find enough detail information on the codes to determine correct usage.  Current cpt book only has minimum descriptions, not enough documentation to know if the billing mulitiple stent placements &/or removals was entered correctly.  Any & All assistance is very Much Appreciated!


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## TNavarre (Jul 30, 2009)

*Your Assistance Needed, Please*

Please any guidance, guidelines, informational websites are needed for correct coding & billing of Dr's services.  The coding info I have is not enough to be sure that services are correctly coded & need documented reassurance/knowledge.

The original post is very long w/detailed info of a couple of the procedures.  Again, this pt has had multiple similiar procedures, _due to previous complications from procedures for weight reduction, (by another physician) _& I really need to find coding guides on this subject to correctly code, appeal &/or get reimbursed properly.  Thanks for your help!


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## LLovett (Jul 30, 2009)

I always suggest encoderpro.com. You can sign up for a free 30day trial. 

This is what I get when I look up 43256

Code Description      

 43256  
Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transendoscopic stent placement (includes predilation)  



Code History      

  This code was most recently made effective or revised prior to: (01/01/2004).  



Lay Description      

 The physician uses an endoscope to examine the upper gastrointestinal tract and performs a transendoscopic stent placement. The physician passes an endoscope through the patient's mouth into the esophagus. The esophagus, stomach, duodenum, and sometimes the jejunum are viewed. The endoscope is placed at the site of an obstruction or stricture, the necessary stent length is determined and predilation of the obstruction or stenosis may be performed. The stent (endoprosthesis) is introduced into the site of the obstruction. Using a commercial delivery system a plastic covering over the stent is removed and the stent self-deploys, shoring-up the walls at a specific site in the esophagus or proximal small intestine. When necessary, a balloon catheter is placed into the stent and gently inflated to more fully deploy the stent. The delivery system and endoscope are removed.  

There is more information that this, but I think this is kind of what you are going for.

Hope this helps,

Laura, CPC, CEMC


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## TNavarre (Aug 28, 2009)

*Multiple stent placement &/or removal*

Reading the above definition I do not see that it is for more than one stent placement.  I believe if more than 1 stent is placed, then Dr should have additional reimbursement.  

If multiple stents are removed & again stents are replaced/repositioned, I believe Dr should recieve add'l reimbursement.  A extensive procedure is done, add'l time & knowledge, etc. equal add'l payment.

Do you code both stent removal & placement when both services are provided?

I appeal'd BC's denial of the payment of more than one placement, orig. denied as dup.  The same for multiple removals w/multiple placement/repositioning.  No add'l $ was paid for the additional services.  My Level II Appeal denied as well.

Where can I find more info on these codes?  Define descriptions & if add'l reimbursement should be paid for multiple placements, removals &/or both.


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