Gastroenterology Coding Alert

Selecting the right imaging codes may be simple – but knowing how to report them isn’t.

Performing upper endoscopies can be more accurate when the physician also perform an endoscopic ultrasound (EUS) – but coding these services isn’t always accurate or easy. Read on to know more about how you can tackle these coding scenarios and avoid denials.

Capture Extent of Use

To accurately report endoscopy procedures with ultrasound, you’ll need to know the extent and the location of the scope visualization AND the regions examined by ultrasound. If, after reading the operative report, there is still a question about how far and what part(s) the physician examined, it is best to query the physician. Documentation is extremely important in assigning the appropriate codes, so coders should discuss documentation requirements with providers to ensure maximum reimbursement along with correct coding.

Example: If your gastroenterologist only examines the esophagus by performing esophagoscopy with endoscopic ultrasound, you can report the procedure with 43231 (Esophagoscopy, flexible, transoral; with endoscopic ultrasound examination). But if the pyloric channel is reached or if your gastroenterologist examines any area up to the jejunum, then you should report the procedure using esophagogastroduodenoscopy (EGD) with EUS CPT^® code 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).

Know How to Tackle This Procedure Variation

If your gastroenterologist performs an upper endoscopy to examine the esophagus, stomach, and either the duodenum and/or jejunum but only examines the esophagus (one region) using endoscopic ultrasound, you report the procedure with 43237 (Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures).

Example: You read in the procedure note that a 66-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 blocking the lumen of the esophagus. Your gastroenter­ologist then performs a EUS to determine the extent of the tumor in the esophagus. He also proceeds to visually examine the other parts of the stomach and duodenum to see if there any other tumors that result with no other significant findings. You code the procedure with 43237 as he only used the ultrasound in the esophagus but also examined the stomach, duodenum, and jejunum with the endoscope.

Switch to Different Code Sets When You Observe a Biopsy

When your gastroenterologist performs an esophagoscopy for fine needle aspiration (FNA) with EUS, then you would report the procedure with 43232 (Esophagoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s). This may be used to aspirate or biopsy a mass of the esophagus that is suspicious for malignancy.

But if your gastroenterologist uses the endoscope (with EUS) beyond the esophagus for biopsy, then you need to switch to other codes. When a physician uses an upper endoscope to complete a fine needle aspiration beyond the esophagus, 43242 (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)) is assigned. This procedure may be used to aspirate or biopsy a mass that may be suspicious for malignancy in the stomach, duodenum, and/or jejunum, and is commonly used to aspirate/biopsy pancreatic pseudocysts.

If your gastroenterologist performs a fine needle aspiration biopsy of the esophagus and then 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)). This code also includes the endoscopic ultrasound limited to the esophagus so it is not separately billable. Gastroenterologists may use this procedure to aspirate or biopsy a mass of the esophagus along with diagnosis any other stomach issues that may be occurring such as acid reflux or ulcers. When biopsy is performed of lesions visually seen rather than via ultrasound FNA, the usual endoscopy/biopsy code (e.g. 43239) with 59 modifier (different site/lesion) can be reported the same day.

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