Gastroenterology Coding Alert

A potential $280 reimbursement could slip through your fingers if you fail to report control-of-bleeding correctly.

When your gastroenterologist performs EGD to control upper gastrointestinal bleeding, you might not look beyond a sole CPT code to report the procedure.

Here's a case straight from a physician's operative report to illustrate:

Procedure: Esophagogastroduodenoscopy with submucosal injection of epinephrine and bipolar cauterization.

Indication for the procedure: Upper GI bleeding. Please see full dictated note dated September 15, 2011.

Medication: General anesthesia

Primary care physician: None

Findings: After informed consent was obtained and satisfactory cardiopulmonary assessment, a time-out as well as medication reconciliation was performed. The Pentax video upper endoscope was then introduced through the oropharynx into the esophagus under direct visualization and progressively advanced. Examination of the esophagus revealed a severely ulcerated and necrotic looking esophagus from the

midportion of the esophagus all the way to the distal portion. At the level of the EG junction, which was at about 40 cm from the incisors, an ulceration was noted with a visible vessel that was actively oozing. Submucosal injection with 4 mL of epinephrine was performed and bipolar cauterization applied with good hemostasis achieved. The scope was also advanced into the stomach. Examination of the gastric mucosa on both forward and retroflexed view revealed diffuse active gastritis with erythema and small erosions, but no active bleeding noted within the stomach. The scope was also straightened then advanced through the pylorus into the duodenum. Examination of the duodenal bulb down to the second portion of the duodenum was unremarkable. The scope was then withdrawn, and the procedure terminated.

Impression:

1. Ulcerative/necrotic esophagus.

2. Distal esophageal ulceration with visible vessel, status post submucosal injection with epinephrine and bipolar cauterization with good hemostasis.

3. Acute erosive gastritis.

Recommendations:

1. Continue monitoring in the intensive care unit.

2. Start IV antibiotics.

3. Continue IV PPI therapy.

4. Continue octreotide for at least 72 hours.

5. Abdominal ultrasound to rule out ascites.

6. Foley placed in the OR as well as an arterial line.

7. Following.

Mark 43255 As Your Go-To Control-Of-Bleeding Code

Since the physician performs the injection and cautery specifically for hemostasis purposes, you should report the only code appropriate for this procedure: 43255 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with control of bleeding, any method). CPT® 43255 accurately describes control of bleeding by "any method," including injection.

Income: Expect to get $288.46 from payers as reimbursement (8.49 nonfacility RVUs multiplied by the 2011 conversion factor of 33.9764) when you bill 43255.

The most common causes of acute upper gastrointestinal bleeding include esophageal varices (456.0, Esophageal varices with bleeding), gastritis (535.51, Unspecified gastritis and gastroduodenitis with hemorrhage), duodenitis (535.61, Duodenitis with hemorrhage), arteriovenous malformations (747.61, Gastrointestinal vessel anomaly), and duodenal ulcers (532.4x). Make sure you check the documentation and determine what sort of bleeding your gastroenterologist treated before you link the condition to 43255.

Leave Out 43255 When GI Causes Bleeding

You have to be careful with one thing: You cannot report control of bleeding if the gastroenterologist causes the bleeding. You should call on control-of-bleeding codes only "when treatment is required to control bleeding that occurs spontaneously, or as a result of traumatic injury (noniatrogenic), and not as a result of another type of operative intervention," as indicated by AMA's Principles of CPT Coding.

For example, the gastroenterologist performs endoscopy with biopsy, which caused the patient's duodenal ulcer to bleed. She then injects epinephrine into the ulcer to control active bleeding. In this case, you would code only the biopsy (43239, Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple), and not the control of bleeding since this scenario is considered standard of treatment during the procedure.

Rule of thumb: If the gastroenterologist caused the bleeding, then you cannot bill any work needed to stop the bleeding using a separate code or using a modifier on the primary code.