Gastroenterology Coding Alert

Question: A patient with severe upper abdominal pain reported to the office for an endoscopy. The gastroenterologist induced conscious sedation with a 25-milligram injection of Demerol, inserted the endoscope and biopsied the patient's gastric mucosa. How should I code this visit?

Arkansas Subscriber
 
Answer: There are two answers to this question, and which one is correct depends on whether the carrier is Medicare or a private payer.

Medicare: If you are filing this claim with Medicare, report 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple) linked with 789.0x (Abdominal pain) for the endoscopy. Medicare payment for endoscopic services performed in the office setting includes an additional payment (site-of-service differential) to cover the cost of the equipment, disposable supplies, and medication.

You cannot report the conscious sedation separately if you're filing with Medicare carriers, because it is bundled into their endoscopy codes.

Tip: For the sake of good record-keeping, it may be wise to document the conscious sedation on the patient's file and enter it into the office computer system with a zero-dollar amount. If you use this method, your office can track conscious sedations, but they won't be reported to the insurance company.

Private payer: If you are filing this claim with a private carrier, you should report the conscious sedation, because some insurers will reimburse for the service. Report 43239 first, then 99141 (Sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation). Use the same ICD-9 code (789.0x [Abdominal pain]) for 43239 and 99141, then report J2175 for the Demerol.

Not all carriers will pay for conscious sedation, but some will. Your ability to be reimbursed for the conscious sedation service will depend on your commercial carrier's policy and, if applicable, your contract with that carrier.  If you don't know the individual insurer's policy on conscious sedation, call the insurer and ask if it will reimburse for conscious sedation. 

 -- 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