Gastroenterology Coding Alert

Question: Our gastroenterologist did a dilatation on a patient who has a severe stricture. He performed the EGD and did an injection of Kenalog in different areas of the stricture using the sclerotherapy needle. Then he advanced the endoscope back into the stomach, left the guide wire and did the dilatation. How should I code for this?

Michigan Subscriber

 
Answer: There have been many questions lately about how to code for dilation and Kenalog injection combinations. In your situation, the gastroenterologist performed an EGD with dilation over a guide wire, which should be reported with code 43248 (EGD; with insertion of guide wire followed by dilation of esophagus over guide wire), says Roberta Classen, CPC, CPC-H, a member of the AAPC National Advisory Committee and lead coder at Charleston Gastroenterology Specialists in South Carolina.
 
In other instances, the dilation could be performed with a balloon of less than 30 mm in diameter (43249). The dilation could also be a nonendoscopic manipulation without a guide wire (43450).
 
There is no CPT code for the Kenalog injection, so Classen recommends using 43499 (unlisted procedure, esophagus) to report it. The Kenalog injection is a cortisone injection used to reduce the inflammation of an esophageal stricture or obstruction, and the fact that a sclerotherapy needle was used is really not an issue, Classen says. The CPT code for sclerotherapy [43243] is specifically for esophageal or gastric varices, not strictures.
 
Some gastroenterology practices may be tempted to attach modifier -22 (unusual procedural services) to the dilation code instead of reporting the unlisted-procedure code, but Classen feels that the unlisted-procedure code is more appropriate in this case. Modifier -22 means that the procedure was performed as stated in the CPT description but is more difficult, more time-consuming or more complex than usual, she explains. Modifier -22 should be used if multiple methods were used for dilating the stricture, but the Kenalog injection is really a separate procedure.
 
When reporting an unlisted-procedure code, an operative report must be included with the claim along with a statement describing the steps taken in performing the Kenalog injection, Classen adds. This separate report should include the typical time taken to complete the procedure and mention a listed code that is the closest equivalent to the Kenalog injection. The sclerotherapy code [43243] might be the most similar to the Kenalog injection, and you might want to base your fee on that codes fee, Classen says. You are going to have to fight for an unlisted procedure, even if you send the proper documentation. You have to follow up on the claim and may have to appeal.