Gastroenterology Coding Alert

Question: Our gastroenterologist recently performed an EGD to assess complaints of abdominal pain for a patient who had previously undergone a gastric bypass? The procedure notes read, "Surgical "ring"from anastomotic pouch was reached endoscopically. Blind pouch measured approximately 10 cm. The efferent, true limb was traversed. Approximately 40cm from the efferent limb's opening, bile was visualized. The Roux anastomosis was not seen. Can you help by letting me know what code I should report for this procedure?

Michigan Subscriber

Answer: Since your gastroenterologist is assessing the patient for his abdominal complaints by performing an upper EGD, you will have to report the procedure with the upper EGD code. As according to the procedure notes it can be inferred that he is only visualizing the gastrointestinal tract for complications of his gastric bypass, you will have to report the procedure with 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).