Gastroenterology Coding Alert

Question: When coding anesthesia for a screening colonoscopy and esophagogastroduodenoscopy (EGD) with biopsy (during a single encounter), should I report the anesthesia twice since there were two procedures?

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Answer: The key to answering this lies in the fact that this is a single encounter involving both upper and lower GI procedures, and the assumption a trained anesthesia provider such as a doctor (MD) or a certified registered nurse anesthetist (CRNA) provided the anesthesia and the patient was not under moderate sedation given by the endoscopist.

The CPT^® anesthesia section guidelines state that you should report the anesthesia code that crosses to the most complex procedure when the patient has multiple surgical procedures during a single anesthetic administration. However, for upper and lower GI procedures during the same encounter, you’ll use 00813 (Anesthesia for combined upper and lower gastrointestinal endoscopic procedures, endoscope introduced both proximal to and distal to the duodenum).