Gastroenterology Coding Alert

Question: Our gastroenterologist saw a new inpatient for complaints of sudden onset severe lower epigastric tenderness. The patient had been seeing signs of bleeding in his stool for the previous few days. He had a history of chronic duodenal ulcers and previous gastrojejunostomy three years ago, after which he had had no signs and symptoms until now. Our GI physician examined him and noted paleness of the sclera, skin, and nails. He also noted epigastric tenderness, tachycardia, and hypotension. He ordered lab tests and performed an upper EGD, which caused him to notice hemorrhaging. He controlled it with electrocautery. The physician’s documentation supported a level three inpatient visit, and he recorded a diagnosis of acute gastrojejunal ulcer with hemorrhage. Which codes apply?

Texas Subscriber

Answer: You should report the evaluation of the patient using 99223 (Initial hospital care, per day, for the evaluation and management of a patient…). You’ll report the EGD procedure done to control the bleeding with 43255 (Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method). And to round the coding out, you’ll report the diagnosis with K28.0 (Acute gastrojejunal ulcer with hemorrhage). Applying a 25 modifier (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M service clarifies that it was a separately reportable service.