Gastroenterology Coding Alert

Question: Our gastroenterologist recently performed an upper EGD procedure. During the procedure, he located two large polyps in the second part of the duodenum and several small sessile polyps in the same area. He first raised the two large polyps with a submucosal saline injection and then removed them with a snare. He also ablated the edges of the large polyps and placed hemoclips to mitigate potential bleeding from the site of removal. The smaller polyps were also removed using the snare. He also used a savory dilator to dilate a cervical esophageal stricture. During the same session, he also used a side viewing duodenoscope to get a better visualization of the ampulla and obtained a biopsy of the ampulla. Please let me know what codes I need to report for the various procedures that our gastroenterologist performed.

Indiana Subscriber

Answer: You will report 43251(Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) for the removal of the various polyps in the second portion of the duodenum. If you see the descriptor for 43251, it shows that you can report the same code for one polyp or more than one polyp. You can also report the submucosal injections separately with 43236 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed submucosal injection(s), any substance) as this is not a standard part of the procedure for the polyp removal by the snare. The application of the hemoclips prophylactically to decrease the chance of bleeding and the ablation of the edges of the same polyps removed by snare technique are part of the removal of the same polyp and cannot be reported separately using any other CPT^® codes.

You can report the dilation procedure that your gastroenterologist performed by using 43248 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with insertion of guide wire followed by dilation of esophagus over guide wire) and the biopsy procedure that he performed using 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple). However, since Correct Coding Initiative (CCI) edits bundle 43239 with 43251 with the modifier indicator ‘1’ you can break this bundling using the modifier 59 (Distinct procedural service). You will have to append the modifier to 43239 as this is the column 2 code in the CCI bundling.

In this case scenario, you will report one unit of 43251 for the removal of all the polyps in the second part of the duodenum, 43236 for the submucosal saline injection, 43248 for the dilation using the savory dilator and 43239 with the modifier 59.