Gastroenterology Coding Alert

Answer: Your POS may not necessarily impact your code choices, but you’re correct that the POS is a key factor in determining the endoscopy payment you recoup. Even though push enteroscopy goes deeper than an EGD, that alone isn’t enough for an increased payment.

Why? AMA considers an upper endoscopy with biopsy safe to perform in the office; therefore, your gastroenterologist may perform the procedure in a nonfacility setting. Since there is a significant additional practice expense payment for 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple), you’ll actually earn more for the EGD in the office than you earn for the push enteroscopy — which is typically performed only in a facility setting — even though the push enteroscopy goes farther.

This can be seen when you compare the relative value units (RVUs). Medicare assigns 4.64 RVUs for 44361 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with biopsy, single or multiple) in both the facility and non-facility settings. However, code 43239 has only 4.06 RVUs in a facility setting but 11.34 in a non-facility setting (based on the CY 2023 Medicare Physician Fee Schedule).