Gastroenterology Coding Alert

Question: A patient presented to the office for his scheduled esophagoscopy with biopsy. Before the procedure, the patient recounted having severe, generalized stomach pain, and vomiting spells in the past week. The gastroenterologist performed the esophagoscopy, and then provided level-two evaluation and management service for the stomach pain and vomiting. I know that I should bill a level two E/M service, but what other codes should I report?New Jersey SubscriberAnswer: Remember this: You can report a procedure code and the E/M service only if you prove that the gastroenterologist performed the esophagoscopy with biopsy, then lent separate time and expertise to the patient's stomach pain and vomiting. To dothis, you must provide rock-solid documentation on both procedures, and link the appropriate diagnosis codes to each service the gastroenterologist provides.For the scenario given, you should:report 43202 (Esophagoscopy, rigid or flexible; with biopsy, single or multiple) for the esophagoscopy.attach ICD-9 code 530.10 [...]