Gastroenterology Coding Alert

Question: I received denials for esophagogastroduodenoscopy (EGD) with dilation (43248) if dysphagia (787.2) was the diagnosis. I reviewed our carrier's Medicare Part B bulletin, which states that dysphagia is an indication, but does not list it as an accepted diagnosis. The only other diagnosis that I can think of is esophageal stricture (530.3). I don't think that would be correct as a preoperative diagnosis, however, because I won't find out until after the procedure whether there is a stricture, and sometimes that might not turn out to be the condition.

Illinois Subscriber

Answer: This sounds like an unfortunate computer glitch. As your carrier's policy states dysphagia is an accepted indication for an EGD, straightforward claims for an EGD dilation with that diagnosis should be appealed if denied. Attach a copy of the carrier's local medical review policy to your appeal and highlight the section that indicates dysphagia as a covered indication.
 
You should also double-check the coding on your claim if the EGD with dilation is being reported in combination with another EGD procedure. Under Medicare's Correct Coding Initiative, the base upper gastrointestinal endoscopy codes 43234 and 43235 are component codes of 43248 and cannot be reported separately.
 
More commonly, the EGD with control-of-bleeding code 43255 is also a component of 43248. If you are also billing 43255 on the same claim and it is appropriate to bill both separately, your problem may be that the claim is missing modifier -59 (distinct procedural service) on the control-of-bleeding code.

This month's Reader Questions and You Be the Coder answered by Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the CPT advisory panel.