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? 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. If, however, the gastroenterologist uses a standard endoscope, she is probably performing an upper GI endoscopy, in which case you would:
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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: