Gastroenterology Coding Alert

Describe a different site biopsy by attaching modifier 59.

If you think you know your way around esophagogastroduodenoscopy coding, get back over it. EGD can be a tricky issue for many medical coders. If you look up the CPT 2011 manual for the word "esophagogastroduodenoscopies," it will point you to "see endoscopy, gastrointestinal, upper," and you'll end up with diagnostic/screening processes or results codes 3130F-3132F, 3140F-3141F. But that's not always the case.

Your operative notes can tell you much more, actually, as they are essentially the only first hand information regarding the procedures performed. Follow along this sample op note, choosing the codes you would report for the EGD procedure, and seeing if they jive with the analysis below.

Probe Op Notes In Depth

Consider the following operative note:

PROCEDURE(S): Upper endoscopy.

INDICATION: Barrett esophagus with low-grade dysplasia.

MEDICATIONS: Versed with monitored anesthesia care as provided by anesthesia service.

FINDINGS: Informed consent was obtained. Risks, benefits, alternatives were explained to the patient. Timeout was performed. The drug list was reconciled. The pentax upper endoscope was introduced. The scope was passed into the 2nd portion of the duodenum. The duodenum appeared normal.

The scope was then withdrawn. Minimal erythema was noted in the stomach. Retroflexion showed a hiatal hernia. The patient was status post nissen fundoplication. The GE junction was at 35 cm and appeared slightly irregular. At the 6 o'clock position, there was a 1 mm salmon-colored island noted that was just proximal to the GE junction. The remaining other areas of Barrett esophagus appeared to have been ablated. One percent mucomyst was then used to lavage the Barrett tissue and the scope was then reintroduced with a focal 90 degree ablation catheter.

The Barrett tissue was targeted at the 6 o'clock position. Energy was applied twice at 40 watts/sq cm and 12 joules/sq cm. The electrode was then moved to the adjacent tissue at around the 5 o'clock position. Again, energy was applied twice at the same settings. Ablation zone was cleaned of coagulative debris. The ablation electrodes and endoscope were then removed, cleaned, and then reintroduced. A second complete ablation set was applied.

The endoscope and ablation catheter were then removed. Approximately 4 treatments in total. Despite the ablation, there appeared to be persistent island tissue noted at the 6 o'clock position. Then, I proceeded to biopsy the GE junction at 9 o'clock, 12 o'clock, and 3 o'clock. The scope was then withdrawn.

IMPRESSION: Short-segment Barrett esophagus. There appeared to be a persistent remaining area of Barrett tissue despite ablation.

RECOMMENDATIONS: We will need to resurvey the esophagus in 3 months, at which time I may need to consider Duette or EMR of the tissue.

Query: How should I bill the following op report? Should I just bill for the ablation?

Barrett's Ablation: Cut To The Chase With 43258, 43239

Since the physician performed ablation and biopsy on several distinctly separate areas, you would code the following:

• 43258 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with ablation of tumor[s], polyp[s], or other lesion[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique) to describe the EGD with ablation.
• 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple) appended by modifier 59 (Distinct procedural service) to indicate that a separately identifiable different location/site was biopsied -- the gastroesophageal junction.
• 530.85 (Barrett's esophagus) linked to 43228 and 43239 to describe the patient's condition.

Because there are so many variations of the upper GI endoscopy, documentation must clearly describe the service. If the physician removed a lesion -- as in this case -- the method (i.e., hot biopsy forceps, snare, or ablation) should also be indicated in the procedure notes, as well as at the top of the operative report.

Quick fact: Barrett's esophagus is the abnormal growth of intestinal-type cells above the esophagus-stomach border. Dysplasia refers to abnormalities within the cells, so Barrett's with high-grade dysplasia means the cells are really messed up. Barrett's with high-grade dysplasia is a higher risk factor for cancer developing in the esophagus than Barrett's with low-grade dysplasia.