Gastroenterology Coding Alert

Question: We performed an EGD on a patient whose x-ray showed a sliding hiatal hernia, and we reported 43270, but the payer denied it. We bill these every day and are unsure what the issue is.

Arkansas Subscriber

Answer: The answer depends on the details of the patient’s hiatal hernia, whether it was symptomatic, and other details. Part B provider Novitas Solutions maintains a policy for Arkansas that includes “X-ray findings of asymptomatic or uncomplicated sliding hiatus hernia” among the indications for which the EGD is not covered. It also isn’t clear from your question whether there is another diagnosis code that requires an ablation because a hiatal hernia is not treated with EGD.

Therefore, if you reported 43270 (Esophagogastroduo­denoscopy, flexible, transoral; with ablation of tumor[s], polyp[s], or other lesion[s] [includes pre- and post-dilation and guide wire passage, when performed])  for a patient with an asymptomatic or uncomplicated sliding hiatal hernia, chances are that this explains why you received a denial.

However, if your physician is certain that the patient’s condition warranted the procedure, you should appeal the claim with the appropriate ICD-10 codes that demonstrate the medical necessity for the service and that show that the patient was symptomatic.