Gastroenterology Coding Alert

Don’t hesitate to report 43239 with 91035 on the same day.

Do you get sick to your stomach when it comes to reporting GERD (gastroesophageal reflux disease)? This may constitute one of the most frequent complaints in a gastroenterology practice. That means you have to know how to recognize and code for GERD from common symptoms to complicated cases and additional tests as well.

Basics: Also known as heartburn and acid regurgitation, GERD results from an incompetent lower esophageal sphincter (the valve separating the esophagus and stomach), which allows the stomach acid to travel up to the esophagus or the food pipe.

ICD-10 has two codes for GERD, but the descriptors do not include the term GERD:

• K21.0 (Gastro-esophageal reflux disease with esophagitis)
• K21.9 (Gastro-esophageal reflux disease without esophagitis).

Usually, providers can recognize GERD from common symptoms but complicated cases may need additional tests to be definitively diagnosed. Here are five scenarios to help you make the distinction.

History Is Enough to Arrive At Dx

To begin with, you need to comb through the history, signs and symptoms of the patient. Take this example:

Scenario 1: A patient presents with a complaint of heartburn. The provider takes a problem-focused history, identifies that this is a recurrent problem, which is interfering with the patient’s daily routine. He performs an examination as well. Satisfied with the history and symptoms of the patient, the provider assigns a confirmed diagnosis of GERD and starts the patient on GERD medication to relieve the symptoms.

The main diagnosis: If your provider identifies GERD, you will need to assign one of the two ICD-10 codes for GERD. In this scenario, as the provider confirms a diagnosis of GERD, we would code it as K21.9 (Gastro-esophageal reflux disease without esophagitis). You may want to be sure about whether the patient has esophagitis or not, before assigning this code. Don’t worry about sending a query to your provider yet. You can code K21.9 as a default code for GERD as it includes esophageal reflux NOS.

Signs and symptoms: “As for coding signs and symptoms, remember these are only to be coded when there is no definitive diagnosis,” says Catherine Brink, BS, CMM, CPC, CMSCS, CPOM, president, Healthcare Resource Management, Inc. in Spring Lake, NJ. “If patient has heartburn, indigestion but GERD has not been specifically diagnosed…then the signs and symptoms would be coded.” For example:

• R12 (Heartburn)
• R05 (Cough)
• K30 (Functional dyspepsia)
• R06.2 (Wheezing)
• J37.0 (Chronic laryngitis)
• J37.1 (Chronic laryngotracheitis).

Don’t forget: Remember to report appropriate diagnosis codes with an E/M code from 99202-99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making….) for reporting the encounter.

Important: “These symptoms can sometimes also be caused by cardiac or pulmonary problems,” says Weinstein. So make it a point to report any pre-existing chronic conditions and habits that may exacerbate GERD such as asthma (J45.-), obesity (E66.-), smoking, pregnancy and hereditary predisposition.

Check Out Endoscopy for GERD

If a basic history taking does not suffice, some providers resort to endoscopy. Here’s an example:

Scenario 2: A patient with problems of heartburn, dysphagia and weight loss presents to the provider. He complains that his symptoms were not relieved even after lifestyle changes and medications. In this scenario, the provider decides to investigate the cause further using an endoscopy, and diagnoses the case as chronic GERD.

Explanation: “Confirming a GERD problem will usually be accomplished by performing an upper endoscopy” says Michael Weinstein, MD, former representative of the AMA’s CPT® Advisory Panel. In this procedure, also known as an esophagogastroduodenoscopy (EGD), the provider uses an endoscope to observe the upper GI tract under sedation. “Other symptoms may warn of complications from chronic GERD,” adds Weinstein. “Complaints of swallowing difficulty, unexpected weight loss, or vomiting may also prompt early endoscopic investigation.”

You can choose from within the code range 43235-43259 (Esophagogastroduodenoscopy, flexible, transoral,…) to report the procedure. The provider can perform this test at a hospital or an outpatient center.

Differentiate Between Standard pH and Bravo Test

Explore your coding options for acid reflux tests with this example here:

Scenario 3: A patient complains of heartburn, acidity and cough. Not sure of the symptoms, the physician orders an esophageal pH test, for diagnosing the condition. Do you think the provider could have opted for any other test to find the cause of the symptoms?

Explanation: An esophageal pH test is a “gold standard” for diagnosing GERD, where the provider determines the amount of time the acid remains in the esophagus, using either a disposable or a reusable nasal catheter. You may report 91034 (Esophagus, gastroesophageal reflux test; with nasal catheter pH electrode[s] placement, recording, analysis and interpretation) for a standard pH test.

Note: You can bill for the same code without modifier even in cases of a “reduced service” or “unusual service” encounter regardless of how long the catheter remains in place.

Alternative test: If the provider decides to have a prolonged measurement (48 hours) of acid exposure in the esophagus, he may perform a Bravo test where he places a small, wireless capsule in the esophagus just above the LES to measure and send the information of the acid refluxing into the esophagus. The provider analyses the information after it is downloaded in a computer. For the Bravo test, you should code 91035 (Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode placement, recording, analysis and interpretation) instead of 91034.

Caution: “In some patients the pH data is inconclusive and patients taking regular acid suppression medication will not get accurate data,” says Weinstein.

Explore Gastric Causes of Chest Pain with Esophageal Manometry

Esophageal manometry is yet another additional test your provider may perform for further investigation. Look at this case:

Scenario 4: A patient complains of severe acidity, coughing and chest pain for over two months. The patient has been taking anti-acidity medication, and previous pH testing was inconclusive. The provider performs an esophageal “motility study” with perfusion for the patient. How do we code for this procedure?

Explanation: In certain abnormal cases, the pH testing methods may not suffice and your provider may need to resort to “esophageal manometry” or the esophageal “motility study” to evaluate the function of muscles of the esophagus. In this test, the provider places a catheter with a sensor tip in the esophagus, to record pressure variations during swallowing and ingestion of food. For the basic test you may report 91010 (Esophageal motility [manometric study of the esophagus and/or gastroesophageal junction] study with interpretation and report).

The GI may add a stimulating agent in motility testing. He may also order acid perfusion (Bernstein) test studies alongwith manometry to confirm whether a symptom of chest pain has been really caused due to GERD. In this case, you will report the add-on code +91013 (... with stimulation or perfusion…).

Handle Multiple Tests with Ease

Here comes a mixed bag scenario, where provider performs two tests on the same day:

Scenario 5: A patient presents with a history of GERD. The provider performs an EGD as well as a biopsy. After identifying the exact location of the lower esophageal sphincter, he inserts a Bravo capsule using the delivery catheter.

Explanation: In this case, even if your provider performs EGD and Bravo study for the same patient on the same date of service, you may be able to report both the procedures separately, and ask for separate reimbursement too. What’s more, you may report the services without any modifier.

The primary code for the EGD would be 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple). Then, you will go on to report 91035 for the Bravo capsule insertion the provider performed during the same session but remember to bill this with the date of service when the provider collects the recorded data; usually, two days later. Don’t forget to mention the primary diagnosis of GERD (K21.9) to demonstrate medical necessity.

Final takeaway: “These gastrointestinal diagnostic services require equipment to gather the data, the technical component, and then analysis of the data by a physician, the professional component,” says Weinstein. “The CPT^® codes for these tests include a value for each component. If your physician owns the technical equipment and performs the analysis then you will bill both components, the global fee, using the appropriate CPT^® code without a modifier. But if the equipment is owned by another entity, the hospital for example, then you will bill only for the professional analysisportion and the service is identified using a modifier26 (Professional component) attached to the CPT^® code. The hospital will then bill for the technical component using the same CPT^® code with a modifier TC (Technical component).”