Gastroenterology Coding Alert

Question: A patient reported for an upper gastrointestinal endoscopy (EGD) with stricturoplasty, and we're stumped on which code to use. Should we report the base EGD code, or is there a CPT code that would compensate the gastroenterologist for the extra work?


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Answer: Because CPT has no code for EGD with stricturoplasty, you have two choices, each with its own benefits and drawbacks:

Option 1: You could report 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]) for the EGD with stricturoplasty.

Pro: Your carrier will almost certainly accept the base EGD code.

Con: An EGD with stricturoplasty takes significantly more work than a standard EGD, so the gastroenterologist will probably be undercompensated for his time, effort and expertise.

Option 2: You might also report 44799 (Unlisted procedure, intestine).

Pro: If the insurer accepts 44799, you will likely receive more claim money.

Con: Medicare does not assign relative value units to 44799, so Medicare will likely not accept the claim.

Even with a private payer, reimbursement is uncertain when you use an unlisted-procedure code--but it is possible. If you file 44799 for the EGD with stricturoplasty, you can strengthen your initial claim by ensuring you have the proper ICD-9 code(s) linked to the procedure, such as 537.0 (Acquired hypertrophic pyloric stenosis) to represent the reason for the stricturoplasty and  include in the operative notes an explanation of the amount of work the duodenal drain added to the procedure.

Of course, as with any unlisted-procedure code, don't be surprised if you have to appeal.