Gastroenterology Coding Alert

Question: Our surgeon performed an EGD that required dilation for access. Upon examination of the duodenum, the surgeon biopsied a suspicious lesion. How should we bill this?

Ohio Subscriber

Answer: You can bill for both the Esophagogastroduodenoscopy (EGD) dilation and biopsy by reporting 43248 (Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator[s] through esophagus over guide wire) and 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple).

There is no Correct Coding Initiative (CCI) edit that restricts reporting these two codes together, and although CPT® instruction restricts you from reporting many codes in addition to 43248, code 43239 isn’t one of them.

Expect pay reduction: Although there’s no bundling restriction on reporting these codes together, you can expect payers to impose a multiple-procedure payment reduction on the second scope. In other words, the payer will fully reimburse the procedure with the highest Relative Value Units (RVUs) and reimburse 50 percent of the amount for the service with lower RVUs.

Modifier: Although most payers used to require you to report modifier 51 (Multiple procedures) when you performed multiple procedures, that’s not the case anymore. In fact, many Medicare payers will reject a claim with modifier 51, although some Medicaid payers still require the modifier. Follow payer instruction to decide whether to use this modifier.