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Gastroenterology Coding Alert

Reader Question:

Choose Between 2 Codes for EGD With Stricturoplasty Drainage

Published on Fri Jul 30, 2004

Question: A patient reported for an upper gastrointestinal endoscopy (EGD) with stricturoplasty, and we're stumped on which code to use. Should we report the base EGD code, or is there a CPT code that would compensate the gastroenterologist for the extra work?

Arizona Subscriber

Answer: Since CPT now has no code for EGD with stricturoplasty, you have two choices, each with its own benefits and drawbacks:

Option 1: You could report 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]) for the EGD with stricturoplasty.

Pro: The base EGD code will almost certainly be accepted by the insurance carrier.

Con: An EGD with stricturoplasty takes significantly more work than a standard EGD, so the gastroenterologist will probably be undercompensated for his time, effort and expertise.

Option 2: You might also report 44799 (Unlisted procedure, intestine). Pro: If the insurer accepts 44799, you will likely receive more claim money. Con: Medicare does not even assign relative value units to 44799, so it's unlikely Medicare will accept the claim.

Even with a private payer, reimbursement is uncertain when you use an unlisted-procedure code -- but it is possible. If you file 44799 for the EGD with stricturoplasty, you can strengthen your initial claim by:

  • ensuring you have the proper ICD-9 code linked to the procedure, such as 537.0 (Acquired hypertrophic pyloric stenosis) to represent the stricturoplasty
  • including in the operative notes an explanation of the amount of work the duodenal drain added to the procedure.

    Of course, as with any unlisted-procedure code, don't be surprised if you have to appeal.

    -- Clinical and coding expertise for You Be the Coder and Reader Questions provided by Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the CPT advisory panel; and Linda Parks, MA, CPC, CCP, coding and billing coordinator for GI Diagnostic Endoscopy Center in Marietta, Ga.

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