General Surgery Coding Alert

Any of more than 20 CPT codes may best describe an upper gastrointestinal (GI) procedure. Accurate coding depends on knowing exactly what the surgeon did and the final destination of the scope. Additionally, if more than one endoscopy is performed during the same session, the coder must know when HCFAs multiple-endoscopy rule applies and how payment for the operative session may be affected.

Although some upper GI procedures, such as endoscopic retrograde cholangiopancreatography (ERCP), are mainly performed by gastroenterologists, many general surgeons perform other GI endoscopic procedures, such as esophagogastroduodenoscopy (EGD), percutaneous endoscopic gastrostomy (PEG) tube placement, biopsies and lesion removals.

The base code for this endoscopic family is 43235 (upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), which should be used when the surgeon performs a diagnostic EGD. Other procedures performed with an EGD include biopsy (43239), placement of PEG tube (43246, see story this issue), removal of foreign body (43247), dilation of esophagus with (43248) and without (43249) guide wire, removal of lesion by hot biopsy forceps (43250) or snare (43251) techniques, ablation of lesion (43258) and control of bleeding (43255).

Because there are so many variations of the upper GI endoscopy, documentation must clearly describe the service. Further, if a lesion is removed, the method (hot biopsy forceps, snare or ablation) should also be indicated in the procedure notes, as well as at the top of the operative report.

Choosing Esophagoscopy or Upper GI Endoscopy

If specific landmarks are not reached during the scope, the procedure may not qualify as an upper GI scope and may need to be billed as an esophagoscopy.

CPT lists 12 esophagoscopy codes, many of which parallel the upper GI codes (biopsy, foreign body and lesion removal, for example). To further complicate matters, an EGD includes work, such as lesion removal, in the esophagus.

CPT does not include gastroscopy codes. If the endoscope passes the esophagogastric (EG) junction into the stomach but is not moved beyond the pylorus into the duodenum (or jejunum, in some cases), only an esophagoscopy may be billed.

If, for example, while removing an esophageal lesion by snare, the surgeon moved the scope past the EG junction into the stomach but did not go as far as the pylorus, 43217 (esophagoscopy, rigid or flexible; with removal of tumor[s], polyp[s] or other lesion[s] by snare technique) should be used. However, if an esophageal lesion is removed but the scope crossed the pyloric valve into the duodenum (and the medical necessity for doing so is documented), an EGD was performed and 43251 (upper gastrointestinal endoscopy ... with removal of tumor[s], [...]