Gastroenterology Coding Alert

Question: I have a report that states the gastroenterologist performed an upper gastrointestinal endoscopy (EGD) on a patient with a Dieulafoy lesion. The physician documented that they removed a significant amount of fresh blood and clots from the fundus and gastric body. Removing the blood clots required using a basket and snare.

Do blood clots count as foreign bodies? How should we bill the procedure?

New Hampshire Subscriber

Answer: Let’s start with the procedure coding. You’ll assign 43255 (Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method) to report the EGD procedure. Also, review the physician’s documentation to see if the notes clearly indicate that the gastroenterologist had to spend a substantial amount of extra time and effort to remove the blood and blood clots from the body structures. If the documentation is sufficient enough to show the added time and effort, you can append modifier 22 (Increased procedural services) to 43255.

Next, blood clots are not considered foreign bodies since they form within the body. According to the CPT^® guidelines, “an object that is unintentionally placed (eg, trauma or ingestion) is considered a foreign body.”

Mike Shaughnessy, BA, CPC, Development Editor, AAPC