Gastroenterology Coding Alert

Question: Last week, a patient presented with diarrhea and anemia. The gastroenterologist performed an endoscopy and took a biopsy of the duodenum to rule out celiac disease. Should I report an upper gastro endoscopy code, or do payers consider this procedure a small intestinal endoscopy?

Ohio Subscriber Answer: It depends on what type of scope your gastroenterologist used during the procedure. Before sending out the claim, make sure you double-check your coding with the gastroenterologist  - but you can look at the operative report for clues as to what type of endoscopy took place.
 
Pore over the procedure notes and check for a scope type. If the gastroenterologist used a pediatric colonoscope or dedicated push enteroscope, this usually indicates a small intestinal endoscopy, in which case you would:
   report 44361 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with biopsy, single or multiple) for the procedure.
   attach ICD-9 codes 787.91 (Diarrhea) and 783.21 (Loss of weight) to 44361.  If, however, the gastroenterologist uses a standard endoscope, she is probably performing an upper GI endoscopy, in which case you would:
 report 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with   biopsy, single or multiple) for the procedure.
   attach ICD-9 codes 787.91 and 783.21 to 43239.