Gastroenterology Coding Alert

Hint: Accurate coding lies in the specific area visualized.

Endoscopic ultrasound (EUS) services are common yet coding these imaging procedures may not always be easy. As you know, what happens during the procedure and how the gastroenterologist documents it can significantly influence how you code EUS services.

If your EUS coding could use some refining, read through this overview to sharpen those skills.

Pay Close Attention to Extent and Location of Scope

For precise reporting of endoscopy procedures that involve ultrasound, it’s essential to understand the scope’s range and location of visualization as well as the areas inspected during the ultrasound.

Examples: A patient is suffering with difficulty swallowing and unexplained chest pain. The CAT scan or chest X-ray shows abnormal tissue that might be in the wall of the esophagus or adjacent to it. This prompts the gastroenterologist to perform an examination of the esophagus via esophagoscopy with endoscopic ultrasound.

Because the exam included a look at the esophagus and nothing beyond, you can report the procedure with 43231 (Esophagoscopy, flexible, transoral; with endoscopic ultrasound examination).

However, let’s say the doctor performs the same procedure but goes past the esophagus and into the duodenum. That would call for 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). Similarly, if the doctor examines the jejunal limb(s) of a patient after gastric surgery, you would also report the procedure using 43259.

Understand This Procedure Variation

Suppose your gastroenterologist performs an upper endoscopy to examine the esophagus, stomach, and either the duodenum and/or jejunum — but only uses the endoscopic ultrasound to examine the esophagus (one region) instead. In this case, you should report the procedure with 43237 (… with endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures).

Example: You read in the procedure note that a 68-year-old male patient presents with symptoms of dysphagia, heartburn, chest pain, severe vomiting, and choking sensations, and your gastroenterologist performs a thorough E/M and decides to perform an EGD. During the procedure, your gastroenterologist finds a tumor in the lumen of the esophagus. The physician then performs an EUS to determine the extent of the tumor. They also proceed to visually examine the other parts of the stomach and duodenum to see if any other abnormalities exist with no other significant findings.

For this situation, you’d code the procedure with 43237, as the physician only used the ultrasound in the esophagus, even though they also examined the stomach, duodenum, and jejunum with the endoscope.

Be Aware of Biopsies

Commonly, the gastroenterologist will choose to biopsy the masses found with the EUS. For example, to aspirate a suspicious mass in the esophagus wall or in a lymph node outside the esophagus, your gastroenterologist would perform an esophagoscopy for fine needle aspiration (FNA) with EUS (if the abnormality is inside the esophagus, tissue sampling would be via routine biopsy rather than FNA via EUS).

CPT^® also provides codes for FNA performed during EUS exams. “The key to deciding which of the preceding codes you should use is identifying the area visualized by the surgeon during the procedure,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, billing specialty subject matter expert at Kareo in Irvine, Calif.

Here are a few of the codes with clinical examples:

43232: When your gastroenterologist performs an esophagoscopy (EGD) for FNA with EUS to aspirate or biopsy a mass that’s in the esophagus, then you would report the procedure with 43232 (Esophagoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s)). (Esophagoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s)).

43242: If your gastroenterologist uses the endoscope with EUS with FNA beyond the esophagus for biopsy, you’ll report 43242 (… (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)). This procedure may be used to aspirate or biopsy a mass that’s considered suspicious for malignancy in or adjacent to the stomach, duodenum, and/or jejunum, and is commonly used to aspirate/biopsy pancreatic lesions. To meet this code requirement, the provider must perform the EUS in each region of the esophagus, stomach and duodenum or jejunum if the stomach was altered surgically.

43238: If your gastroenterologist performs EUS of a single region and performs an FNA biopsy of that region but uses the endoscope to visually examine the stomach and either the duodenum and/ or jejunum, you should report the procedure with 43238 (Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), (includes endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures)

Note: Code 43238 also includes the EUS limited to the esophagus, so it is not separately billable. Gastroenterologists may use this procedure to aspirate or biopsy a mass or abnormal lymph nodes of the esophagus, stomach, or duodenum, along with examining for any other upper digestive issues that may be occurring, such as acid reflux or ulcers. When the gastroenterologist performs a biopsy of lesions seen visually rather than via ultrasound FNA, you can report the usual endoscopy/biopsy code (e.g., 43239) with modifier 59 (Distinct procedural service) on the same day.

CPT^® provides three additional codes for FNA performed during EUS exams. Like with the previous three codes, look carefully at the descriptors to find the correct code for the procedure described by your gastroenterologist:

• 45392 (Colonoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures)
• 44407 (Colonoscopy through stoma; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures)
• 45342 (Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s))

Coding alert: Report flexible sigmoidoscopy instead of colonoscopy if your surgeon doesn’t advance the scope beyond the splenic flexure, according to CPT^® instruction.

Caution: Do not bill radiology codes 76942 (Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation) or 76975 (Gastrointestinal endoscopic ultrasound, supervision and interpretation) if your gastroenterologist performs EUS. CPT^® provides specific instructions not to report 76942 and 76975 with codes 43232, 43238, and 43242.

Remember: Proper documentation plays a crucial role in assigning the correct codes, so always be on the lookout for opportunities for provider education. This ensures not only accurate coding but also optimal reimbursement. If the operative report leaves any doubts about the extent and specific parts examined by the physician, query the provider. “Documentation is an area that is always evolving. Doctors want to do their job to the best of their abilities and are willing to learn where there documentation needs more detail,” said Halee Garner, CPC, CPMA, CCA, certified coder for Digestive Health Partners in Asheville, North Carolina.