Gastroenterology Coding Alert

Question: Is separate reimbursement for conscious sedation administered during an upper gastrointestinal endoscopy (EGD) possible? A woman with severe, persistent pain in her upper-right abdomen reported to our gastroenterologist. The gastroenterologist performed an EGD with intravenous conscious sedation to alleviate the pain, but I am not sure whether I should report the sedation.

Arkansas Subscriber

Answer: Whether you report the sedation depends on the carrier. Medicare will not reimburse for conscious sedation during an EGD, so do not try with any of its carriers. Since 2006, CPT now defines groups of codes that include moderate (conscious) sedation in Appendix G.

For Medicare payers, you should:

• 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.

• link 789.01 (Abdominal pain, right upper quadrant) to 43235 to represent the patient's pain.

Private payers: With private payers, you may be able to gain payment only if your contract calls for conscious sedation payment when the physician uses it during an EGD. First, find out if your carrier accepts conscious sedation codes in this type of encounter.

If the carrier accepts the codes with EGD codes, then you should report:

• 43235 for the EGD

• 99143 (Moderate sedation services) for the sedation.

Remember to link 789.01 to 43245 and 99143 to account for the patient's abdominal pain.