Gastroenterology Coding Alert

Question: Our physician performed an EGD for a patient with upper gastrointestinal bleeding and bleeding in the stomach. The procedure revealed blood clots and some old blood in the antrum, but the gastro could find no active ulcer. The doctor injected epinephrine in the duodenal bulb to prevent future bleeding. How should I report this procedure?

Missouri Subscriber

Answer: Since there was a clot and the gastroenterologist was trying to prevent further bleeding, report 43255 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with control of bleeding, any method).
 
Make sure the operative notes indicate that the gastroenterologist performed the injection to control bleeding; if he was not injecting to control bleeding, you should report 43236 (... with directed submucosal injection[s], any substance).

 - Clinical and coding expertise for this issue 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, an independent coding consultant in Marietta, Ga.