Gastroenterology Coding Alert

Collect a $800+ profit for joint 43235, 91035, and E/M.

When evaluating a patient for gastroesophageal reflux disease (GERD), gastroenterologists could perform an esophagogastroduodenoscopy (EGD) to examine the lining of the esophagus, stomach, and upper duodenum.

Background: EGD is a diagnostic endoscopic procedure considered to be minimally invasive since it doesn't require an incision into one of the major body cavities and doesn't usually necessitate any significant recovery after the procedure unless anesthesia has been used.

If you think you know your way around EGD coding, go back over it. You might find out that choosing the appropriate ICD-9 code to fit your patient's condition is just as important as getting your CPT®s right. Steer clear of complications by picking up a few strategies from these two EGD coding cases.

Case 1: Dig Up $855 From EGD + Reflux Test Treatment

Scenario: A new patient reports to the gastroenterologist complaining of recurrent belching and heartburn. The physician performs a diagnostic EGD. During the procedure, the physician finds no evidence of any cancer or severe esophagitis. He also inserts a Bravo capsule to confirm the presence and severity of suspected reflux. How should you report this?

You would report the EGD and the Bravo insertion separately. Here's how you should report the encounter:

• 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]) for the EGD;
• 91035 (Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode placement, recording, analysis and interpretation) to describe the Bravo cap insertion;
• 787.1 (Heartburn) and 787.3 (Flatulence, eructation, and gas pain) appended to 43235 and91035 to represent the patient's symptoms.

Revenue: You should get about a total of $784.48 in reimbursement for procedures (EGD and Bravo insertion). CPT® 43235 should pay back about $297.97 (8.77 RVUs multiplied by the 2011 conversion factor 33.9764). Insurance could compensate about $486.51 for 91035 (14.32 RVUs multiplied by the same conversion factor).

Case 2: Fit Anesthesia Administration During EGD Where Necessary

Scenario: An anesthesiologist provided anesthesia during an esophagogastroduodenoscopy (EGD) procedure, at the request of the attending gastroenterologist. The physician notes that the request was due to the patient's symptoms, but no other details were provided. In the documentation, we included proof that the anesthesiologist administered Propofol. We coded the anesthesia portion with 00810, but our claim was denied. What do you advise?

Reasons for denial do not always focus on how you've coded your procedures. Sometimes, they are found in the lack of codingfor the patient's condition. Don't forget that your diagnosis code should indicate the co-existing medical condition that justifies your anesthesiologist's involvement in the case, not the gastrointestinal condition leading to the endoscopy.

What to do: Consult with your anesthesiologist to verify that the patient had a condition such as:

• Parkinson's disease (332.0)
• Heart conditions (such as 410.xx, Acute myocardial infarction or 427.41, Ventricular fibrillation)
• Mental retardation (318.x)
• Seizure disorders (such as 780.39, Other convulsions)
• Anxiety (such as 300.0x, Anxiety states)
• Pregnancy
• History of drug or alcohol abuse.

The payer might have been looking for any of these conditions to justify the presence of an anesthesiologist at the EGD session. You may also look into two ICD-9 codes describing failed sedation attempts: 995.24 (Failed moderate sedation during procedure) and V15.80 (Personal history of failed moderate sedation), and get a confirmation from your anesthesiologist. "A claim denied by one carrier might be processed smoothly by a different carrier. The policy for anesthesia coverage and payment methodology is not standardized amongst Medicare intermediaries or non- Medicare carriers," explains Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT® Advisory Panel.

Remember: If you used a screening diagnosis or treatment of commonly found conditions instead of the clinical condition requiring anesthesia, payers will not pay you for these services.