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 [...]