Gastroenterology Coding Alert

Removing or moving foreign body -- the answer will lead you to two different codes.

Deciphering whether your gastroenterologist removes a foreign body or simply moves it will determine which code you should report for the procedure. Ensure you're reporting foreign body removal (FBR) procedures appropriately, by knowing three facts.

1. Use 43247 for FBRs With a Scope

If your gastroenterologist actually performs an FBR -- in other words, he extracts the foreign body -- you should report this using an FBR code such as 43247 (Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; with removal of foreign body). Typically your gastroenterologist will use a scope to remove a foreign body in the esophagus. If circumstances support reporting a FBR, you should report it.

Example: Suppose a portion of a percutaneous endoscopic gastrostomy (PEG) tube broke off during removal and the gastroenterologist had to use a scope to extract it. In this case, because the gastroenterologist had to use the scope, you may report the FBR using upper GI endoscopy code: 43247. If the gastroenterologist has no way to remove the portion of PEG tube manually, be sure to show in your documentation the necessity for using the scope to retrieve the portion of the broken tube. Without documentation, the payer will likely reject your claim.

2. Determine if the Foreign Body Was Dislodged or Removed

If your gastroenterologist pushed an obstructing foreign body from the esophagus into the stomach using a scope, you should still consider it to be a removal of the foreign body from the esophagus even if the foreign body wasn't actually removed, says Michael L. Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel. This happens commonly when particulate food debris is 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 impaction 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, ... diagnostic, with or without collection of specimen[s] by brushing or washing [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: If you're worried about the code, you could 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 removing it from the body entirely. If the scope doesn't reach the stomach due to an esophageal stricture then you would use 43215 (Esophagoscopy, rigid or flexible; with removal of foreign body). Also, if your gastroenterologist only partially removed the foreign body, you would not use modifier 52 3. No Scope? Turn to 45915 for FBRs On rare occasions, you may come across a case where your gastroenterologist 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. "For removal of foreign body without a scope, the only one you would consider would be 45915 (Removal of fecal impaction or foreign body (separate procedure) under anesthesia)," says Kathleen Mueller, RN, CPC, CCS-P, CMSCS, PCS, coding consultant in Lenzburg, Ill. But in most cases, you would likely be able to report only an E/M service based on the usual levels.