Gastroenterology Coding Alert

These are 3 of the most commonly-reported GI procedures - test whether you know how to report them.

As a GI coder, you probably see operative reports every day, and you're likely to know many of the codes for these services by heart. But some procedure notes can throw a wrench in the works by adding additional services or falling short of the standard CPT® descriptors, forcing you to find an alternate code or use a modifier.

To get a handle on where your op note coding stands, check out the following three op notes from commonly-performed GI surgeries, and then determine which codes you'd select to report the services.

1. Check This Screening Colonoscopy

A 66-year-old patient presents for a colonoscopy. She has no symptoms and has never had a screening colonoscopy before.

The patient is anesthetized and is positioned in the left lateral decubitus position. During rectal exam, sphincter tone appears normal and no masses are observed. When the colonoscope is introduced into the rectum and advanced to the distal sigmoid colon, a benign appearing sessile polyp is seen in the sigmoid colon, which is measured to be 6 mm in size. I removed and retrieved the polyp using hot biopsy forceps, and monitored blood loss, which was minimal.

Question: Which code should you report among the following?

        A. G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk)
​        B. 45384 (Colonoscopy, flexible; with removal of tumor(s), polyp[s], or other lesion[s] by hot biopsy forceps)
​        C. 45385 (Colonoscopy, flexible; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique)
​        D. 45381 (Colonoscopy, flexible; with directed submucosal injection[s], any substance)

Answer: Your correct answer is (B), code 45384. That's because the surgeon documented removing the polyp by hot biopsy forceps and not by snare technique; he also did not document performing any injections during the procedure.

The reason answer (A) is incorrect is that G0105 is solely reported for a screening colonoscopy. Once the procedure turns diagnostic, you no longer report the screening code and instead you should only report the diagnostic code, which in this case is 45384.

Modifier considerations: Medicare payers require practices to append modifier PT (Colorectal cancer screening test converted to diagnostic test or other procedure)  to the diagnostic colonoscopy code to demonstrate that the procedure started as a screening service but turned diagnostic. However, many private payers instead prefer modifier 33 (Preventive services) appended to the colonoscopy code to show that it started as a screening procedure. Therefore, check with non-Medicare payers to determine whether you must add a modifier on these services.

2. Find out How to Code This Paracentesis Service

A 72-year-old male patient presents with fluid accumulation in his abdomen. After preparation of the abdominal tap kit, the surgeon reconfirmed the border of the ascites and identified a suitable site for paracentesis. After percussion to reconfirm the border, the tap site was marked in the midline 2, cm under the umbilicus. A betadine swab was used to clean the area and the area was then isolated using a sterile drape. The syringe was loaded with the local anesthetic and it was penetrated into the skin at a 90-degree angle while the left hand stabilized the area of penetration.

The anesthetic was then slowly injected into the area with alternate aspiration and injection. I made a slight cut using a number 11 scalpel blade to permit catheter passage, then prepared the flexible catheter and used a large needle to enter the peritoneal space. Negative pressure was applied to help ascertain the location into the peritoneal cavity. The needle was positioned 3 cm into the peritoneal cavity to avoid displacement.

The needle was then held in place with one hand and the catheter was slowly advanced all the way over the needle. Once the catheter was in place, the needle was slowly removed. A large syringe was then attached to the stopcock. Using slow aspiration, the fluid was then collected in the syringe and stored in the vial to be sent to the laboratory for diagnosis.

Question: Which of the following codes applies to this service?

​    A. 49062 (Drainage of extraperitoneal lymphocele to peritoneal cavity, open)
​    B. 49082 (Abdominal paracentesis [diagnostic or therapeutic]; without imaging guidance)
​    C. 49083 (Abdominal paracentesis [diagnostic or therapeutic]; with imaging guidance)
​    D. 49084 (Peritoneal lavage, including imaging guidance, when performed)

Answer: The correct answer is (B), 49082, because it describes the surgeon's work performing the paracentesis. The reason 49062 is inaccurate is become there is no lymphocele. In addition, the procedure is described as an open operation and the doctor performed paracentesis rather than drainage, says Glenn Littenberg MD, a gastroenterologist in Pasadena, Calif.

Many coders often reach for 49083 in paracentesis cases, but a thorough review of this op report reveals that the paracentesis procedure described here was conducted without the use of any imaging guidance.

3. Get A Handle on Coding An EGD

A 73-year-old male patient presents for an EGD procedure. The patient was sedated and placed in the left lateral decubitus position. I inserted a video endoscope via the oropharynx and advanced it to the descending portion of the duodenum without difficulty, where I found a healthy duodenum. I withdrew the scope to the stomach, where gastroscopy revealed no defects. Retroflexion views revealed a hiatal hernia of significant size. I readjusted the scope to the proximal gastric body where the hiatal hernia was measured to be appx. 10 cm in size.

Several Cameron lesions were noted in the distal portion of the hiatal hernia sac, but I did not observe any bleeding. I withdrew the scope through the esophagus, where the esophageal mucosa appeared tortuous. No complications were noted during the procedure, which the patient tolerated well.

Question: To code this esophagogastroduodenoscopy (EGD), which of the following codes should you report?

​    A. 43235 (Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure])
​    B. 43236 (Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection[s], any substance)
​    C. 43237 (Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures)
​    D. 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])

Answer: For this EGD, the correct answer is (A), code 43235. Many coders are thrown off by the "including collection of specimens" statement (and this procedure did not reveal any specimen collection), but the descriptor goes on to say, "when performed." Therefore, you can still report this code whether or not the GI collected any specimens.

Code 43236 isn't appropriate because this op report did not indicate that any injections were performed, and both 43237 and 43238 require ultrasound examinations, which this note did not describe.