Gastroenterology Coding Alert

Hint: It comes down to location and work performed.

Knowing which upper GI procedure codes to report can be confusing for gastroenterology coders. How far the scope goes, what the procedure entails, where it enters the body, all of these factors help you determine which procedure code to use — and sometimes these differences are subtle.

If you’re looking to improve your GI coding game, check out this breakdown of esophagoscopies and esophagogastroduodenoscopies (EGDs). It will help you navigate these often-confusing codes.

Learn What to Look for to Code Esophagoscopies

Simply put, an esophagoscopy gives a provider a means to investigate conditions affecting the esophagus and commonly a small portion of the stomach where the esophagus enters the stomach. Although sometimes parts of the throat (pharynx) and vocal cord area (larynx) are seen, esophagoscopy is distinguished from pharyngoscopy or laryngoscopy. The procedure serves to examine the esophagus lining and function, take tissue samples, dilate strictures, or simply unblock the esophagus clogged by foreign bodies.

There are several types of esophagoscopy procedures: transoral, where the provider passes the esophagoscope through the patient’s mouth, and transnasal, where the provider passes the scope through the patient’s nose. Transoral procedures can also be rigid or flexible:

• Rigid esophagoscopy. This is a transoral procedure using a narrow tube with lenses, light, and an eyepiece. The method can be used to perform minor surgical procedures. Anesthesia is required. This is rarely performed by gastroenterologists and is mostly performed by ENT (head and neck) surgeons.
• Flexible esophagoscopy. This is another transoral procedure, but this one involves thin fibers that run through the endoscope to shine light into the patient’s gut. Because the fibers are connected to a monitor, the provider can see the images. Anesthesia is generally utilized.
• Transnasal esophagoscopy. This is, in theory at least, the least intrusive procedure and does not require anesthesia. The very thin endoscope designed for this purpose goes through the nose and down into the esophagus. This procedure is mostly used for diagnosis rather than surgery, but the gastroenterologist will sometimes perform biopsies with this method.

Codes to look for: Choose esophagoscopy codes from 43180-43233 to report an endoscopic examination of the esophagus (even if the gastroenterologist incidentally enters the stomach, as may happen if the physician needs to gain a retroflex view back at the cardia). Often, you’ll choose from:

• 43191 (Esophagoscopy, rigid, transoral; diagnostic, including collection of specimen[s] by brushing or washing when performed [separate procedure]) or
• 43200 (Esophagoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed [separate procedure])
• 43197 (Esophagoscopy, flexible, transnasal; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure))

Note: For diagnostic transnasal esophagoscopies, use 43197. If your provider also performs a biopsy, CPT^® takes you to 43198 (Esophagoscopy, flexible, transnasal; with biopsy, single or multiple).

When additional services are provided, such as dilation, you may choose a code such as:

• 43220 (Esophagoscopy, flexible, transoral; with transendoscopic balloon dilation (less than 30 mm diameter)
• 43226 (Esophagoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) over guide wire)
• 43214 (Esophagoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed))
• 43212 (Esophagoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed))

Coding alert: If the gastroenterologist performs balloon dilation to address an obstruction prior to placing a stent, do not report 43220 with 43212. Instead, report the procedure using 43212 alone. Although the code does not describe “balloon” dilation, it does specify that the procedure includes pre- and post-dilation, when performed.

Additionally, National Correct Coding Initiative (NCCI) edits bundle 43220 as a Column 2 code for 43212 with a modifier indicator of “0,” meaning that you cannot override the edit pair under any circumstances.

Differentiate EGDs from Esophagoscopies

Compared to an esophagoscopy, an EGD looks further down the patient’s upper GI system and into the stomach and duodenum, or the first part of the small intestine. Also known as an “upper endoscopy,” this procedure helps providers diagnose and treat many disorders of the upper GI tract. Like esophagoscopies, EGDs can be performed using transnasal and transoral approaches.

Note: Even if the physician passes the pylorus and enters the jejunum due to an altered anatomy such as a Billroth II to examine the upper GI tract or after bariatric surgery, you should choose a code from the EGD (43235) family.

Codes to look for: Go for EGD codes 43235-43259, 43210, or 43270. You’ll regularly turn to base EGD code 43235 (Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]), when your gastroenterologist passes the pylorus with the endoscope.

Like esophagoscopies, EGDs can be separated into transoral and transnasal. Sedation is usually required for transoral procedures, while a transnasal EGD typically uses topical anesthesia according to CPT^® Assistant Volume 32, Issue 9 (2022). This means “the transnasal approach may be quicker and more easily tolerated by patients than traditional transoral EGD procedures, as it’s only a numbing medication in the throat and nose,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, billing specialty subject matter expert at Kareo in Irvine, California.

Transoral: There are currently 27 category I codes that describe EGD via a transoral approach, Many of them include additional services in addition to the procedure described by base code 43235, including:

• 43239 (… with biopsy, single or multiple)
• 43241 (… with insertion of intraluminal tube or catheter)
• 43238 (… 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))
• 43254 (… with endoscopic mucosal resection)
• 43270 (… with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed))
• 43233 (… with dilation of esophagus with balloon (less than 30 mm diameter) (includes fluoroscopic guidance, when performed))

Transnasal: CPT^® introduced three category 3 codes for transnasal EGDs that became effective July 1, 2021:

• 0652T (Esophagogastroduodenoscopy, flexible, transnasal; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure))
• 0653T (… with biopsy, single or multiple)
• 0654T (… with insertion of intraluminal tube or catheter)

Remember: The fifth character, T, in the code indicates the service is an emergent technology and CPT^® has assigned the procedure a temporary Category III code.

Realize That Documentation is Key

Like with most procedures, there are some subtle details included within each code set, not just between the esophagoscopy and EGD codes. That means that documentation is going to make or break accurate reporting. For example, if your physician notes they went all the way through the esophagus for a rigid transoral endoscopy, you’ll use a code from 43191-43196 (Esophagoscopy, rigid, transoral …).