Gastroenterology Coding Alert

Even dislodging the foreign body deserves a code.

The way your coding progresses in case of foreign body removal (FBR) will be dictated mainly by whether your gastroenterologist decides to removethe foreign body or simply moves it. Just follow these tips to stay abreast of the procedure codes.

Background: Although ingestion of foreign bodies is a most common occurrence in the young to very young populace, it is not rare in adults. It usually occurs accidentally but can result from deliberate ingestion. Patients with mental illness, intellectual impairment, prisoners or ‘drug-carriers,’ ‘body-packers’ (people smuggling illicit drugs concealed in their gastrointestinal tract) are prone to problems caused by purposeful ingestion of foreign bodies. Trichobezoar is a rare condition where hair ingestion leads to formation of a hairball in the stomach.

Tip 1: Code According to Location

If your gastroenterologist decides on removal, he will perform a procedure known as esophagogastroduodenoscopy (EGD) where the GI inserts a scope through the mouth to view the esophagus, stomach, and duodenum by means of a flexible endoscope. The physician removes the foreign body during this procedure using biopsy forceps. If the physician performs the procedure for FBR in the  lower GI tract, you should report this with 43247 (Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body). However, if the procedure in the upper GI tract, you should use 43215 (Esophagoscopy, flexible, transoral; with removal of foreign body).

Example: A patient is confirmed with a diagnosis of esophageal foreign body (a coin), no notable associated comorbidities. The relevant ICD-9 code is 935.1 (Foreign body in esophagus). The gastroenterologist decides upon esophagoscopy with removal of foreign body. The case note in case of a typical example of 43215 may read, “Under general anesthesia, flexible EGD was performed. Esophagus was visualized. The quarter was visualized at the aortic knob, and the removal was done with a grasper. Estimated blood loss 0.”  

Note: The code 43215 is for flexible transoralesophagoscopy. If you encounter a rigid transoralesophagoscopy, then you should code it with 43194 (Esophagoscopy, rigid, transoral; with removal of foreign body) that has been specially added in 2014.

If the gastroenterologist has no way to remove the foreign body manually, be sure to show in your documentation the necessity for using the scope to retrieve the object. Without documentation, the payer will likely reject your claim.

Tip 2: Dislodged but Not Removed? Still Code This

In some cases, the foreign object may be obstructing the esophagus but is not a good candidate for outright removal due to its location or the danger of complications. In such a scenario, your gastroenterologist may decide to push or dislodge the obstructing foreign body from the esophagus into the stomach using a scope.You will still code it as a removal of the foreign body from the esophagus, even if the foreign body wasn’t actually removed. This happens commonly when particulate food particles are clumped above an esophagus stricture and cannot be removed as a single foreign body.

Example: If your gastroenterologist performed an esophagogastroduodenoscopy (EGD) on a patient who had a food bolus impacting at the gastroesophageal junction and pushed the food into the stomach, you would bill 43247 even if the foreign body wasn’t removed through the mouth.

Although dislodging a foreign body exceeds a simple diagnostic EGD (43235, … flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed [separate procedure]), your best solution is to report 43247. Most Medicare carriers and commercial payers will not challenge 43247 even when the gastroenterologist does not physically remove the food bolus from the patient.

Note: On rare occasions, you may come across a case where your physician decides to remove a foreign body from the colon without using a scope. Typically in these situations, the patient would be under general anesthesia, and the physician would remove the foreign body while the patient is unconscious. In this case, you should report 45915 (Removal of fecal impaction or foreign body [separate procedure] under anesthesia). But in most cases, you would likely be able to report only an E/M service based on the usual levels. Make sure you consult with your physician before deciding which code to use.

Tip 3: Use Modifier as a Savior

If you’re not too sure about the exact code in case of dislodged foreign object, you could report 43247 with modifier 52 (Reduced services). Do include a brief note in your documentation explaining that the gastroenterologist dislodged the foreign body into the stomach using the endoscope rather than removing it from the body entirely. If the scope doesn’t reach the stomach due to an esophageal stricture, then you would use 43215. Also, if your gastroenterologist only partially removed the foreign body, you would not use modifier 52.