Advanced Search

Gastroenterology Coding Alert

43235 Is the Key to EGD 'Family' Coding Success

Published on Fri May 07, 2004

"

CMS has upped RVUs for several EGD codes

Do you know how frequently biopsies are performed with upper EGDs? Can you list all of the procedures included in the upper EGD family""? Become familiar with these common gastro codes to set your office up for future success.

"

CMS Sees 43235 'Family' Frequently

In the most recent list of top-50 procedures reported in gastroenterology offices the Centers for Medicare and Medicaid Service (CMS) included several codes from the 43235 endoscopy family. This is no surprise to Janene Long billing supervisor at Gastroenterology & Hepatology Associates in Reading Penn. She says the 43235 code family would have several entrants in her office's most-performed-procedures list.

Extra Incentive: These codes were always common in a gastro setting and they're also quite profitable too (see "CMS Grants RVU Increases to 5 Codes in the 43235 'Family' " ). Read on for some expert advice on the 43235 family to ensure you are coding upper diagnostic EGDs the right way every time.

Learn What Makes Up a Family

In order to keep things less complicated for coders and gastroenterologists CPT divides endoscopy codes into families.

Example: Rigid or flexible EGDs are grouped into one endoscopic family: The family code group starts with the base code 43200 (Esophagoscopy rigid or flexible; diagnostic with or without collection of specimen[s] by brushing or washing [separate procedure]) and includes all of the codes between 43200 and 43232 (... with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy[s]).

Families of codes share the same base procedure. "It's just that you do something else in addition [to the base procedure] " says Amanda Morreale billing supervisor for UCLA's Physician Support Services.

Use 43235 as the Base Code 

To best understand the 43235 family start with the base code. The 43235 family's base code is appropriately 43235 (Upper gastrointestinal endoscopy including esophagus stomach and either the duodenum and/or jejunum as appropriate; diagnostic with or without collection of specimen[s] by brushing or washing [separate procedure]) and all codes up to 43259 (... with endoscopic ultrasound examination including the esophagus stomach and either the duodenum and/or jejunum as appropriate) are part of the family.

The base code includes the diagnostic upper EGD and every other code in the family represents a procedure in which the EGD is performed in addition to something else Morreale says. Let's say the gastroenterologist performs an upper diagnostic EGD with biopsy; you would report 43239 (... with biopsy single or multiple) instead of 43235. 

Some indicators for a diagnostic EGD include:

  •  persistent upper abdominal distress despite trial of therapy
  •  upper abdominal distress with symptoms suggesting a serious organic disease such as anorexia and weight loss
  •  dysphagia or odynophagia
  •  persistent or recurrent esophageal reflux symptoms despite a trial of therapy
  •  persistent vomiting with no known cause.

    When filing a 43235 claim be sure the notes describe the patient's symptoms. Also include the appropriate ICD-9 codes where applicable. The more legitimate documentation and relevant diagnosis codes you have on your claim the better.

    Example: An established patient reports to the office while battling a spell of profuse vomiting. He also complains of intense nausea. The gastroenterologist performs a diagnostic EGD to find the cause and location of the vomiting.

    On your claim report 43235 with the ICD-9 codes 536.2 (Persistent vomiting) and 787.01 (Nausea with vomiting). Further fortify the claim with specific notes describing the patient's condition paying special attention to the vomiting spells and nausea.

    Watch EGDs With Biopsies

    Whenever the gastroenterologist performs an upper diagnostic EGD make sure you check the operative notes for any other task performed keeping an especially sharp eye out for the word "biopsy."

    "I would say 95 percent of the time they take biopsies of something" during an EGD Long says.

    "If a patient comes in for a diagnostic EGD complaining of heartburn or upper gastric pain the doctor will do a biopsy if there's any kind of inflammation or irritation " Long says.

    Coding example:  An established patient reports to the office complaining of severe epigastric pain. The gastroenterologist performs an EGD and finds a gastric ulcer which he biopsies.

    On your claim report 43239 with the ICD-9 code 789.06 (Abdominal pain; epigastric). Don't let the ICD-9 codes do all the talking on your claim though. Operative notes with more information on the patient's abdominal pain will only fortify the report.

    "They're pretty generic procedures but you definitely want to have your diagnosis codes to support [43235 and 43239] claims " Long says. "You have to support medical necessity in all situations."

    Tip: Morreale says she has very little trouble in her office when reporting EGD family codes. 

    She recommends getting coders gastroenterologists and nurses on the same page when reporting codes from
    the 43235 family by setting up specific charge sheets and making sure everyone understands their contents.

    Review Your LMRP

    First step: When formulating your office's 43235 charge sheet review the Medicare local medical review policies to help you select ICD-9 codes that meet the criteria of medical necessity for EGD procedures.

    "We never have a problem [reporting] for the 43235 family " she says. "Our doctors are very educated about coding themselves and they know all of the right diagnoses and we have our charge sheets set right down to body part."

    "

    • Other Articles in this issue of

    Gastroenterology Coding Alert

    View All