Gastroenterology Coding Alert

Reviewed on May 15, 2015

Payment is down for endoscopic ultrasound procedures performed with fine needle aspiration, but you can capture your practice’s maximum, ethical reimbursement by following five simple steps.

Step 1: Determine EUS Code

The ultrasound codes for the upper endoscopies are used to measure depth of lesions “masses or tumors in the lungs esophagus and pancreas,” says Vonda Reeves-Darby MD Gastrointestinal Associates Jackson Miss. When the physician uses an esophagoscope with endoscopic ultrasound (EUS) you should report 43231  (Esophagoscopy, flexible, transoral; with endoscopic ultrasound examination). For an esophagogastroduodenoscopy (EGD) with EUS assign 43259  (Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination, including the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis).

Use the same code for an EUS of the pancreas.

Remember if the physician does not examine past the esophagus code an esophagoscopy (43231). However, “an esophagoscopy becomes an EGD (43259) when the pyloric channel has been reached,” says Linda Ming, CPC, Gastrointestinal Associates, Jackson, Miss. In addition, a documented reason must exist for examining the liver adrenal gland or pancreas.

“Sigmoidoscopies also have ultrasound codes,” Reeves-Darby explains. “These are sometimes used when the patient has had fecal incontinence or scar tissue.” For a flexible sigmoidoscopy with EUS bill 45341 (Sigmoidoscopy flexible; with endoscopic ultrasound examination).

Step 2: Combine Appropriate EUS and FNA Codes

Each of the above EUS codes corresponds to a fine needle aspiration (FNA) code. When the gastroenterologist performs esophagoscopy with EUS and FNA report 43232  (Esophagoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy[s]).

For EGD with EUS/FNA assign (Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy[s] [includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis).

For a rectal exam with EUS/FNA use flexible sigmoidoscopy code (Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy[s]).

Do not report the EUS code in addition to the FNA code. For example, suppose a gastroenterologist performs an EGD with EUS/FNA. Bill 43242 only. CPT® includes the diagnostic EGD code (43259) in the surgical EGD (43242).

Step 3: Bill Allowed Radiology Codes

When the physician supervises and interprets the needle placement or the endoscopic ultrasound, CPT® and the Correct Coding Initiative (CCI) have prohibited the use of two radiology codes:

  76942 Ultrasonic guidance for needle placement (e.g. biopsy aspiration injection localization device) imaging supervision and interpretation

  76975 Gastrointestinal endoscopic ultrasound supervision and interpretation.

 You cannot report 45342 with 76942 or 76975

When 76942 is performed with 43232 or 43242 report the surgical procedure only. CCI 8.1 made supervision and interpretation (S&I) code 76942 a component of the comprehensive EUS/FNA codes (43232, 43242).

According to CPT®, you cannot report 76975 with 43259 under any circumstances. CPT® already stipulates “do not report 76975 in conjunction with 43231, 43232, 43242, 45341, and 45342.”

Step Four: Report Two Related Services

If the gastroenterologist performs Doppler studies or administers a celiac nerve block report each of these services in addition to the surgical procedure.

CPT® describes two codes that pertain to Doppler studies of the abdomen and pelvis:

  93975: Duplex scan of arterial inflow and venous outflow of abdominal pelvis scrotal contents and/or retroperitoneal organs; complete study

  93976: …limited study.

Gastroenterologists usually use code 93976. Code 93975 denotes a complete study examining the arterial flow and velocity. This level of examination normally exceeds the gastroenterologist’s scope of practice and medical necessity.

For instance, suppose a physician performs an EGD with EUS on a patient who has abdominal pain. The doctor wants to further examine the abdominal blood flow to ensure it’s not restricted and causing the pain. Report 43259, 93976. For the EGD with EUS use 43259. For the limited Doppler study assign 93976.

If the doctor examines the mediastinum or aorta report 93979 (Duplex scan of aorta inferior vena cava iliac vasculature or bypass grafts; unilateral or limited study). However, a gastroenterologist rarely needs to scan these areas.

For a celiac nerve block assign 64680 (Destruction by neurolytic agent, with or without radiologic monitoring; celiac plexus). Consider the same example of the patient who has stomach pain. The doctor uses an EUS-guided celiac plexus neurolysis to destroy the sympathetic nerves. He also supervises and interprets the endoscopic ultrasound. The claim should read: 43259, 64680, 93976. Report each service in descending-value order: The EGD with EUS (43259) has 4.14 work relative value units (RVUs) for 2015. The nerve block (64680) has 2.67 work RVUs. The Doppler study (93976) has 0.80 work RVUs.

Step Five: Append Modifier -26

When you report the radiology and Doppler studies and the physician does not own the equipment append modifier -26 (Professional component) to the service. The Medicare Physician Fee Schedule breaks 76942, 76975, 93975, 93976, and 93979 into a professional and technical component. Most EUS procedures are performed in a hospital setting, which means the facility owns the equipment and bills for its use and the physician codes for work performed.

For the above celiac nerve block scenario assume the gastroenterologist performs the EGD with EUS at a hospital. Bill 43259, 64680, 93976-26. Modifier -26 indicates that you are charging for the physician’s work only. If he owns the equipment do not append modifier -26.