Gastroenterology Coding Alert

Question: Our gastroenterologist recently saw a new patient who was referred by their general practitioner. During the consultation, the gastroenterologist decided the patient needed an esophagogastroduodenoscopy (EGD) and biopsy which the doctor performed that same day. Can I report the consultation with the procedure?

North Carolina Subscriber

Answer: Yes, you can. Keep in mind though, that since the patient has only been evaluated by their general practitioner, the gastroenterologist should establish and document a definitive diagnosis (or exclusion) prior to advising treatment.

Assuming that occurred, you’ll report the appropriate consultation code along with the EGD CPT^® code. Depending on the specifics of the consultation, as written in the medical notes, as well as the associated medical decision making (MDM) level, you may assign either of the following 2023 evaluation and management (E/M) codes:

• 99243 (Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.)
• 99244 (… 40 minutes must be met or exceeded.)

The counterpart codes for Medicare or payers who don’t recognize consultation codes would be 99203/4 (Office or other outpatient visit for the evaluation and management of a new patient… low/moderate level… 30-44/45-49 minutes…) for a new patient. To indicate to the payer that the E/M code was separately identifiable and not just the “usual” pre-procedure work, the 25 modifier (Significant, separately identifiable evaluation and management service by the same physician…) is appended to the E/M code. Then assign the appropriate EGD code, such as 43235 (Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)) to report the procedure.