Gastroenterology Coding Alert

Question: Our GI recently performed the following procedure. How should I code it?

Procedure: Upper GI endoscopy

Indications: Severe pancreatitis complicated by peri-pancreatic fluid collection s/p endoscopic cyst-gastrostomy now with persistent cavity despite endoscopic drainage here for direct endoscopic exploration. abdominal pain, nausea.

Complications: No immediate complications.

After obtaining informed consent, the endoscope was passed under direct vision. Throughout the procedure, the patient’s blood pressure, pulse, and oxygen saturations were monitored continuously. The Endoscope was introduced through the mouth, and advanced to the antrum of the stomach. The upper GI endoscopy was accomplished without difficulty. The patient tolerated the procedure.

Findings:

--Three previously placed, double-pigtail, trans-gastric stents were seen in the body of the stomach. Two of the stents were removed with a snare. The cyst-gastrostomy tract was cannulated with a wire-guided balloon dilator and the tract was dilated using a 15-16.5-18mm TTS balloon dilator up to a maximum diameter of 18mm. The cyst cavity was then endoscopically explored. The entire cavity was filled with solid necrosis. Some of the solid necrosis was removed endoscopically using lavage and suction. As the patient became tachycardic at this time and there was a large amount of solid necrosis within the cavity, the decision was made to replace the double-pigtail stents and place a naso-cystic tube to attempt to reduce the amount of solid necrosis within the cavity. During this time, the last remaining double-pigtail stent spontaneously migrated out of the cyst-gastrostomy tract and into the stomach. This was removed with a grasping forceps. Two 7Fr by 7cm plastic, double-pigtail stents were then placed across the cyst-gas­trostomy tract. Then one 7Fr naso-cystic tube was placed.

-- A previously placed gastrostomy tube was seen with a jejunal extension entering the duodenum. The jejunal extension was removed during the procedure (and not replaced) to facilitate work on the cyst-gastrostomy tract.

-- The exam of the stomach was otherwise normal.

New Jersey Subscriber

Answer: The procedure seems to be a stent placement. You should report code 43266 (Esophagogastroduodenoscopy, flexible, transoral; with placement of endoscopic stent [includes pre- and post-dilation and guide wire passage, when performed]). If the op notes specify extra work/time due to the abnormal findings, you could also consider modifier 22 (Increased procedural service) requiring work substantially greater than typically required to get paid for the extra effort put in by the physician. However, ensure detailed documentation to justify the modifier.

The descriptor of the code includes dilation, therefore, do not report dilation codes 43245 (.. with dilation of gastric/duodenal stricture(s) [e.g., balloon, bougie]) in conjunction with 43266. Medicare will deny any claim for a single session that includes both 43245 and 43266.