Gastroenterology Coding Alert

Question: Our physician will often inspect the submucosal area during upper and lower GI endoscopy and inject a therapeutic drug. Which codes apply to this?

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Answer: The correct code depends upon the location of the injection – whether the physician was performing an upper or lower GI.

Upper GI: If your physician performs an upper endoscopy with injection, you have an option to report one of the following codes:

• 43192 (Esophagoscopy, rigid, transoral; with directed submucosal injection(s), any substance)
• 43201 (Esophagoscopy, flexible, transoral; with directed submucosal injection(s), any substance)
• 43236 (Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance).

You should report 43236 for submucosal saline injections for lifting polyps, botulinum toxin injection (for achalasia), India ink (for tattooing), steroid injection, or any other substance, excluding a sclerosant for esophageal/gastric varices or epinephrine to control bleeding. Look at the extent of the scope travelled to decide if the procedure was an esophagoscopy (43201) or an esophagogastroduodenoscopy (EGD, 43236). Injections to help with endoscopic mucosal resections (EMR) may contain other substances with saline like methylene blue or hyaluronic acid that help define the edges of the polyp to be removed, but the injection service in the case of EMR is bundled with the EMR service and cannot be separately reported.

Hint: Endoscopy that includes the duodenum or jejunum via gastroenterostomy as part of the examination is an EGD.

Lower GI: If your gastroenterologist performs a lower endoscopy with an injection, you’ll instead report one of the following codes, based on whether the physician performs a sigmoidoscopy or colonoscopy:

• 45335 (Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance)
• 45381 (Colonoscopy, flexible; with directed submucosal injection(s), any substance)
• 44404 (Colonoscopy through stoma; with directed submucosal injection(s), any substance)

Caution: According to the CPT^® guidelines, you should not separately report these injection codes in conjunction with control of bleeding and endoscopic mucosal resection codes for the same lesion and location. Some payers will require a 59 modifier (Distinct procedural service) with the secondary (injection) code particularly for upper GI procedures; CMS does not have an edit that requires 59 for 45381.