Gastroenterology Coding Alert

Dislodging FB may not be the same as removal

If the gastroenterologist removes any object not part of the human anatomy, he technically performs a foreign- body removal (FBR). Unfortunately, this straightforward logic doesn't carry over into coding principles.

To be sure you-re reporting FBR procedures appropriately, you-ll have to answer three questions.

1. Was a Scope Required?

If the gastroenterologist can remove the foreign body without using a scope, you won't report an FBR, says Linda Martien, CPC, CPC-H, coding specialist with National Healing in Boca Raton, Fla. In such cases, you-ll likely be able to report only an E/M service at the level best supported by the physician's documentation of the patient encounter.

Example: The patient arrives for a follow-up office visit for the purpose of removing a percutaneous endoscopic gastrotomy (PEG) tube. The gastroenterologist removes the tube without complication. Here again -- although the PEG tube is a foreign object -- you should not report an FBR code. The gastroenterologist did not have to perform an -invasive- procedure using a scope to remove the PEG tube.

Note: You cannot report a separate code for simple PEG tube removal because CPT contains no such code. If the gastroenterologist removes the tube only, you can report only an appropriate-level outpatient E/M code (99201-99215), says Kathleen Mueller, RN, CPC, CCS-P, a registered nurse and reimbursement and coding specialist in Lenzburg, Ill.

2. Was Endoscopy Nonroutine?

If circumstances support reporting a FBR, you should report it -- just make sure you have the documentation to report it.

Example: Suppose, however, that a portion of the PEG tube broke off during removal in the example above, requiring the gastroenterologist to use a scope to extract it. In this case, because the gastroenterologist had to use the scope, you may report FBR using upper GI endoscopy code 43247 (Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; with removal of foreign body).

Why? Although Chapter 6 of the National Correct Coding Initiative stipulates that -CPT code 43247 is not to be reported for routine removal of therapeutic devices previously placed,- this is not a -routine removal.-

In this case, the gastroenterologist has no way to remove the portion of PEG tube manually. Your documentation should make clear, however, the necessity for using the scope to retrieve the portion of the broken tube. Without documentation, the payer will likely reject the claim.

3. If Just Dislodged, Then Is It Removal?

If your gastroenterologist dislodges a foreign body from a patient's esophagus, for example, the gastroenterologist did not technically remove it.

Although dislodging a foreign body exceeds a simple diagnostic EGD (43235, - diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), your best solution is to report 43247. Most Medicare and commercial payers will not challenge 43247 even when the gastroenterologist does not physically remove the food bolus from the patient.

But if you-re nervous about the code, another solution is to report 43247 with modifier 52 (Reduced services). Include a brief note on your claim explaining that the gastroenterologist dislodged the foreign body into the stomach using the endoscope rather than removed it from the body entirely.