Gastroenterology Coding Alert

See how your coding options shift for EUSs with fine needle aspirations

If your gastroenterologist uses upper endoscopic ultrasounds (EUS) to measure the depth of lesions, masses or tumors in the esophagus and pancreas, among other structures, then you know you need to have your EUS codes on hand. Simplify your coding options by breaking down these codes into three categories.

Keep in mind: All the codes used for endoscopic ultrasound are on the approved list for ASC procedures.

1. Examine Your Esophagus EUS Coding Options

When your gastroenterologist performs an EUS on the esophagus, you’ve got two codes from which to choose.

When is EUS limited to the esophagus? The gastroenterologist may use EUS only on the esophagus during an esophagogastroduodenoscopy (EGD) when the patient has esophageal or mediastinum tumors, “particularly if there is a stricture preventing insertion to the stomach,” says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the CPT Advisory Panel.

Limited to the esophagus: For instance, if the physician only examines the esophageal region with EUS, you should report 43231 (Esophagoscopy, rigid or flexible; with endoscopic ultrasound examination).

With EGD: Secondly, for an EGD with EUS, stick with 43259 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with endoscopic ultrasound examination, including the esophagus, stomach, and either the duodenum and/or jejunum as appropriate).

Don’t forget 43237 (… with endoscopic ultrasound examination limited to the esophagus) when your gastroenterologist performs an EGD and EUS in the esophagus. 

Several scenarios may demand EUS all the way to the stomach or small intestine, Weinstein says. “Generally, gastric ulcers, tumors, duodenal masses, strictures, pancreatic mass, pancreatic pseudocyst or ampullary (major papilla) masses” require EUS past the esophagus, Weinstein says.

Example: A patient with a gastric ulcerating mass meets the gastroenterologist in the endoscopic suite for an EGD. The gastroenterologist performs the EGD, using EUS on the gastric mass. On the claim, you should report the following:

• 43259 for the EGD with EUS

• 531.9x (Gastric ulcer; unspecified as acute or chronic, without mention of hemorrhage or perforation) to represent the patient’s ulcers.

Be sure to attach documentation that will fortify the claim. “The report should describe the procedure performed in sufficient detail to pass any post-claim audit,” Weinstein says.

Note: You would use this same code (43259) for an EUS of the pancreas.

Rule of thumb: If your physician doesn’t examine past the esophagus, you should stick with the esophagoscopy code (43231). If he reaches the pyloric channel, however, the esophagoscopy becomes an EGD EUS (43259 or 43237). If this is the case, your gastroenterologist must have a documented reason for examining the stomach, duodenum, liver, adrenal gland or pancreas. “Even if the instrument can be passed lower, there would not necessarily be any indication to use the ultrasound beyond the esophagus,” Weinstein says.

2. Clear Up Your Colonoscopy EUS Confusion

In addition to esophageal EUS, both sigmoidoscopies and colonoscopies have ultrasound codes: 45341 (Sigmoidoscopy, flexible; with endoscopic ultrasound) and 45391 (Colonoscopy, flexible, proximal to splenic flexure; with endoscopic ultrasound examination). Your gastroenterologist might use these procedures when a patient has had fecal incontinence or scar tissue.

Rationale: In the case of 45391, “a gastroenterologist will occasionally encounter an unusual finding during a colonoscopy where there is a mass suspected under the surface of the intestine. These lesions can be assessed with the aid of an ultrasound device that is part of a colonoscope,” Weinstein says.

Example: During a colonoscopy, the gastroenterologist sees a suspicious mass under the patient’s intestine and decides to have a closer look. With the help of an ultrasound device attached to the colonoscope, the gastroenterologist views the suspicious area. In this scenario, you should report 45391.

You cannot report 45378 (… diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]) for the colonoscopy because this is the base code for 45391. And modifiers won’t help you. In other words, you cannot bill these two codes separately. You should only report 45391.

As for your ICD-9 code, this will depend on your finding, Weinstein says. A possibility is 787.99 (Other symptoms involving digestive system; change in bowel habits), but you should only use what your documentation specifies.

3. Combine Appropriate EUS and FNA Codes

Each of the EUS codes corresponds to a fine needle aspiration (FNA) code.

Esophagoscopy and FNA: So when your gastroenterologist performs esophagoscopy with EUS and FNA, you should report 43232 (… with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy[s]).

EGD and FNA: And for EGD with EUS and FNA, assign 43242 (… with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy[s] [includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum and/or jejunum as appropriate]).

Rectal exam: For a rectal exam with EUS and FNA, you would use the flexible sigmoidoscopy code (45342, … with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy[s]) or colonoscopy code (45392, … with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy[s]), depending on which service your physician used.