Gastroenterology Coding Alert

Question: How do I code this procedure? The notes show that the physician performed a small bowel enteroscopy with ablation of duodenal AVMs- (arteriovenous malformations)?

New Jersey Subscriber

Answer: Take a look at 44369 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with ablation of tumor[s], polyp[s], or other lesion[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique). Here’s why:

Step 1: When reading an endoscopic procedure report to determine the correct CPT^® code, your first step is to determine the correct code family. Check out the procedure type, which often includes the furthest extent of the examination (such as esophagoscopy, upper GI endoscopy [EGD], or small bowel enteroscopy).

Step 2: The next step is to look for the intraprocedure services. This will help you determine which therapeutic code(s) to use within the code family. The location where the gastroenterologist performed the therapeutic procedure is not relevant to picking the correct base family of codes. In this case, the procedure is from the enteroscopy code family (44360-44370). Although the gastroenterologist performed “ablation” on duodenal AVMs, the correct code is from the small bowel enteroscopy family of codes, 44369.

Remember: Therapeutic endoscopy always includes diagnostic endoscopy. This means you should look to the base code.

An intravenous malformation (AVM) can occur anywhere within the gastrointestinal tract from mouth to rectum. When you look at your CPT^® definitions, keep in mind that you should consider AVMs to be other lesion(s).