Gastroenterology Coding Alert

Hint: Let the location of ultrasound probe guide your choices.

If your gastroenterologist performs an upper endoscopy along with ultrasound (EUS), don't make the mistake of reporting endoscopy with EUS using upper endoscopy codes, as there are separate codes for these procedures. Read on to know more about how you can tackle these coding scenarios such that it can help beef up your coding accuracy and avoid denials.

Capture Extent of Use

To accurately report endoscopy procedures with ultrasound, you'll need to know the extent and the location of the scope. "If after reading the operative report, there is still a question about how far and what part(s) the physician examined, it is best to query the physician," says Heather Copen, RHIT, CCS-P, Financial Advocate-Goshen OB/ GYN and Goshen GI, IU Health-Goshen Physicians, Goshen, Indiana. "Documentation is extremely important in assigning the appropriate codes," so coders should "discuss documentation requirements with providers to ensure maximum reimbursement along with correct coding," she adds.

Example: If your gastroenterologist only examines the esophagus by performing esophagoscopy with endoscopic ultrasound, you can report the procedure with 43231 (Esophagoscopy, rigid or flexible; with endoscopic ultrasound examination). But if the pyloric channel is reached or if your gastroenterologist examines any area up to the jejunum, then you should report the procedure using esophagogastroduodenoscopy (EGD) with EUS CPT® code 43259 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with endoscopic ultrasound examination, including the esophagus, stomach, and either the duodenum and/or jejunum as appropriate).

Know How to Tackle This Procedure Variation

If your gastroenterologist performs an upper endoscopy to examine the esophagus, stomach, and either the duodenum and/or jejunum but only examines the esophagus using endoscopic ultrasound, you report the procedure with 43237 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with endoscopic ultrasound examination limited to the esophagus). "This is telling the payer that the physician performed a full examination of the esophagus, stomach, and either the duodenum and/or jejunum using the upper endoscope but only examined the esophagus with the endoscopic ultrasound," says Copen.

Example: You read in the procedure note that "A 63-year-old male patient presents with symptoms of dysphagia, heartburn, chest pain, severe vomiting and choking sensations" and your gastroenterologist performs a thorough evaluation and management and decides to perform an EGD. During the procedure, your gastroenterologist finds a tumor blocking the lumen of the esophagus. Your gastroenterologist then performs a EUS to know the extent of the tumor in the esophagus. He also proceeds to examine the other parts of the stomach, the duodenum and the jejunum to see if there any other tumors that result with no other significant findings. You code the procedure with 43237 as he only used the ultrasound in the esophagus but also examined the stomach, duodenum and jejunum with the endoscope.

Switch to Different Code Sets When You Observe a Biopsy

When your gastroenterologist performs an esophagoscopy for fine needle aspiration (FNA) with EUS, then you would report the procedure with 43232 (Esophagoscopy, rigid or flexible; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy[s]). "This may be used to aspirate or biopsy a mass of the esophagus that is suspicious for malignancy," says Copen.

But if your gastroenterologist uses the endoscope (with EUS) beyond the esophagus for biopsy, then you need to switch to other codes. "When a physician uses an upper endoscope to complete a fine needle aspiration beyond the esophagus, 43242 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy[s] [includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum and/or jejunum as appropriate]) is assigned," says Copen. "This procedure may be used to aspirate or biopsy a mass that may be suspicious for malignancy in the stomach, duodenum, and/or jejunum. This procedure is commonly used to aspirate/biopsy pancreatic pseudocysts." If you see this in your procedure notes, you can report it with 43242.

If your gastroenterologist performs a fine needle aspiration biopsy of the esophagus and then uses the endoscope to examine the stomach, and either the duodenum and/ or jejunum, you report the procedure with 43238 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy[s], esophagus [includes endoscopic ultrasound examination limited to the esophagus]). "This code also includes the endoscopic ultrasound limited to the esophagus so it is not separately billable," says Copen. Gastroenterologists may use this procedure "to aspirate or biopsy a mass of the esophagus along with diagnosis any other stomach issues that may be occurring such as acid reflux or ulcers," she adds.

Caution: Do not bill radiology codes 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation) or 76975 (Gastrointestinal endoscopic ultrasound, supervision and interpretation) if your gastroenterologist performs EUS or EUS with FNA. "CPT® gives specific instructions not to report 76942 and 76975 with codes 43232, 43238, and 43242," says Copen.