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Gastroenterology Coding Alert

Esophagogastroduodenoscopy:

Details In The Op Note And Documentation Will Spell The Difference When Coding EGD.

Published on Fri Sep 09, 2011

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 DepthConsider 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, [...]
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