Gastroenterology Coding Alert

Question: Our gastroenterologist injected botulinum toxin for achalasia during an upper endoscopy. How do I report the injection along with the procedure?

Oregon Subscriber

Answer: The injection is considered part of the procedure, so only one code is necessary. Which code you report depends on the details of the procedure and how it was performed. Basically, if your physician performs an upper endoscopy with injection, you have an option to report one of the following codes:

• 43192 (Esophagoscopy, rigid, transoral; with directed submucosal injection(s), any substance)
• 43201 (Esophagoscopy, flexible, transoral; with directed submucosal injection(s), any substance)
• 43236 (Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance)

You would report 43236 if your provider administered a submucosal saline injection (as with endoscopic polypectomy which requires lifting the lesion before removing it by snare), a botulinum toxin injection (for achalasia), India ink (for tattooing), a steroid injection, or any other substance, excluding a sclerosant for esophageal/gastric varices or epinephrine to control bleeding.

Remember: You should look at the distance the scope traveled to decide if the procedure was an esophagoscopy (43201) or an EGD (43236). An endoscopy that includes the duodenum or jejunum as part of the examination is an EGD.