Gastroenterology Coding Alert

Question: I am having trouble recognizing diagnostic upper gastrointestinal endoscopies and have filed several claims incorrectly due to these lapses. What are some indicators in the operative notes that would lead me to code for these procedures?

Montana Subscriber

Answer: You should report the diagnostic upper GI endoscopies, or esophagogastroduodenoscopies (EGDs), with 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).
 
Physicians can use the test to determine several gastrointestinal conditions -- such as esophageal cancer, gastric ulcer and gastroesophageal reflux disease (GERD), to name a few.
 
Suggestion: On the operative reports for a diagnostic EGD, you would commonly see these indications:

 - Persistent upper abdominal distress despite trial of therapy

 - Dysphagia or odynophagia

 - Persistent or recurrent esophageal reflux symptoms despite a trial of therapy

 - Upper abdominal distress with symptoms suggesting a serious organic disease (anorexia, weight loss, etc.)

 - Persistent vomiting with no known cause.

Keep in mind: An EGD report should describe the usual path of the scope entering from the mouth, through the esophagus, into the stomach, and past the pylorus into the duodenum. Look for these anatomic  landmarks in the procedure report. Additionally, your gastroenterologist should not include any mention of obtaining a biopsy, removing a polyp or dilating a stricture.
 
Any mention of a therapeutic maneuver would change the diagnostic EGD into a therapeutic EGD that will have a different CPT code, depending on the additional service he performed. 
 
If you-re unsure, the best advice: Check with the gastroenterologist who filled out the encounter form to make sure it is a diagnostic EGD. Take the time to get the final answer straight from the physician before sending the claim out.

 -- Clinical and coding expertise for this issue provided by Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel; and Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta.