General Surgery Coding Alert

Don’t unbundle separate steps.

Whether down the hatch or up the other end, CPT^® provides a host of codes for ultrasound (US) guided endoscopy procedures that you should master.

The following steps guide you through how you can drill down through the options to make sure you pick the right code, every time.

Step 1: Identify the Scope Procedure

When you read the op report, you should find clear documentation regarding the type of scope the surgeon uses and the surgical approach. That intel will lead you to scope code families that you’ll find among the following choices:

• Esophagoscopy – 43191-43196 (Esophagoscopy, rigid, transoral …), or 43197-43198 (Esophagoscopy, flexible, transnasal …), or 43200-43232 (Esophagoscopy, flexible, transoral …)
• Esophagogastroduodenoscopy (EGD) – 43235-43259 (Esophagogastroduodenoscopy, flexible, transoral …)
• Small intestine endoscopy - 44360-44373 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum …), or 44376-44379 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum)
• Colonoscopy – 45378-45398 (Colonoscopy, flexible …)
• Colonoscopy through stoma – 44388-44408 (Colonoscopy through stoma …)
• Sigmoidoscopy – 45330-45350 (Sigmoidoscopy, flexible …)
• Proctosigmoidoscopy – 45300-45327 (Proctosigmoidoscopy, rigid …)
• Anoscopy – 46600-46615 (Anoscopy …)

Step 2: Drill Down to US Codes

Many, but not all of the endoscopy code ranges listed in the prior section include codes that involve ultrasound guidance. Once you’ve identified the scope and approach, you can look for any US codes in the appropriate CPT^® section to find the following:

• 43231 (Esophagoscopy, flexible, transoral; with endoscopic ultrasound examination)
• 43232 (… with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s))
• 43237 (Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures)
• 43238 (… with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), (includes endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures))
• 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 or a surgically altered stomach where the jejunum is examined distal to the anastomosis))
• 43253 (… with transendoscopic ultrasound-guided transmural injection of diagnostic or therapeutic substance(s) (eg, anesthetic, neurolytic agent) or fiducial marker(s) (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis)
• 43259 (… with endoscopic ultrasound examination, including the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis)
• 44406 (Colonoscopy through stoma; with endoscopic ultrasound examination, limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures)
• 44407 (… with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures)
• 45341 (Sigmoidoscopy, flexible; with endoscopic ultrasound examination)
• 45342 (… with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s))
• 45391 (Colonoscopy, flexible; with endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures)
• 45392 (… with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures)

Step 3: Determine Area Visualized, Additional Procedures

The code families start with a code for “endoscopic ultrasound examination” but the child codes include other procedures your surgeon may add to the exam.

Specifically: If your surgeon performs injection of diagnostic or therapeutic substance(s) during a transoral esophagogastroduodenoscopy, code 43253 describes the procedure.

CPT^® also provides six codes for fine needle aspiration (FNA) performed during endoscopic US (EUS) exams:

• During US esophagoscopy – 43232
• During US EGD – 43238 or 43242
• During US colonoscopy – 45392 or 44407
• During US sigmoidoscopy – 45342

“The key to deciding which of the preceding codes you should use is identifying the area visualized by the surgeon during the procedure,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, billing specialty subject matter expert at Kareo in Irvine, Calif.

For an EGD, 43238 involves examining the area limited to esophagus, stomach or duodenum, and adjacent structures, while 43242 includes exam of esophagus, stomach, and either the duodenum or a surgically altered stomach, plus the jejunum distal to the anastomosis.

For a colonoscopy, the distinction is whether the endoscopic US occurs through a stoma (44407) or with an approach through the anus (45392).

Coder tip: Report flexible sigmoidoscopy instead of colonoscopy if your surgeon doesn’t advance the scope beyond the splenic flexure, according to CPT^® instruction.

Step 4: Don’t Double Dip

The codes for endoscopic US are all inclusive. That means you shouldn’t separately code the following:

• Radiology, such as 76872 (Ultrasound, transrectal), 76942 (Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation), or 76975 (Gastrointestinal endoscopic ultrasound, supervision and interpretation).
• Distinct FNA codes such as 10005 (Fine needle aspiration biopsy, including ultrasound guidance; first lesion)
• Base code for endoscopic US exam, including 43231, 43237, 43259, 44406, 45341, 45391.

Example: Your surgeon documents an esophagus examination via esophagoscopy with US guidance, but the EUS reaches the duodenum and includes examination of the jejunal limb(s) of a patient post-gastric surgery.

In this case, you can report the procedure using the EGD with EUS code 43259, advises Glenn D. Littenberg, MD, MACP, FASGE, AGAF, former CPT^® Editorial Panel member in Pasadena, California.

Even though the op note calls the procedure an esophagoscopy, you should not code this as 43231 because the exam extends beyond to the duodenum and the jejunal limbs.