General Surgery Coding Alert

Watch for multiples.

Your general surgeon might perform endoscopic injections to treat an array of conditions, using an even larger array of agents — and you need to know how to code these cases.

Let us help you make sure you’re not leaving money on the table when your surgeon administers injections during an endoscopic procedure. Read on to learn how to capture the max revenue for your physician’s injection services by following these five golden rules.

1. Choose Injection Code by Endoscope Type

CPT^® provides dedicated injection codes when your surgeon inspects the submucosal area during upper or lower gastrointestinal (GI) endoscopy and injects a therapeutic drug. The physician may also use a submucosal injection to mark a lesion (with a substance such as India ink) or lift a lesion for easier removal.

Upper GI: If your surgeon 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.

Look how far the scope travelled anatomically to decide if the procedure was an esophagoscopy (43201 or 43192) or an EGD (43236).

For instance: “Injections to help with mucosal resections may contain saline with other substances, such as methylene blue or hyaluronic acid, that help define the edges of the polyp to be removed,” says Michael Weinstein, MD, former representative of the AMA’s CPT^® Advisory Panel.

Lower GI: If your general surgeon 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.

2. Stay Away From Injection Codes for Sclerotherapy

Other than marking or therapeutic reasons, one other common use for administering an endoscopy with injection is for sclerotherapy (destruction of varices). In such cases, however, you should forget the injection codes altogether and opt for the sclerosis/destruction codes instead based on location, as follows:

• 43204 — Esophagoscopy, flexible, transoral; with injection sclerosis of esophageal varices
• 43243 — Esophagogastroduodenoscopy, flexible, transoral; with injection sclerosis of esophageal/gastric varices.

3. Get Paid for Separate Procedure Injections

Sometimes your surgeon will perform an endoscopy with injection procedure during the same session as another procedure. You can often use these codes in combination if you have clear documentation.

Example: If your physician performs a polypectomy (such as 45385, Colonoscopy, flexible; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) and tattooing for subsequent resection (45381-45359) during the same session, you can report both procedures.

Example 2: Sometimes, the surgeon may inject the base of a polyp with saline (45381), and then remove the polyp by snare in piecemeal fashion (45385). The surgeon may then inject India ink at the polypectomy site to be able to identify the location in the future. You can also report this second injection procedure with 45381.

4. Endoscopic Mucosal Resection Codes Include Injections

CPT^® codes added in 2014 and 2015 describe endoscopic mucosal resection (EMR) in the upper and lower GI tract. “These codes include the injections that are performed to assist the EMR procedure so do not bill these injections separately,” Weinstein says.

The codes are as follows:

• 43211 — Esophagoscopy, flexible, transoral; with endoscopic mucosal resection
• 43254 — Esophagogastroduodenoscopy, flexible, transoral; with endoscopic mucosal resection
• 45349 — Sigmoidoscopy, flexible; with endoscopic mucosal resection
• 45390 — Colonoscopy, flexible; with endoscopic mucosal resection

5. Consider Separate Coding for Bleeding Control

You can separately report codes for hemostasis (control of bleeding) if the bleeding is the reason for the procedure. According to CPT^® guidelines, when your surgeon uses injection therapy to “control hemorrhage not associated with esophageal or gastric varices,” you can report either of codes 43227 (Esophagoscopy, flexible, transoral; with control of bleeding, any method) or 43255 (Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method).

Beware: If the bleeding is the result of a diagnostic or therapeutic intervention, you should strictly forego the hemostasis codes unless it happens at a separate session, in which case you’ll need to use a modifier such as 59 (Distinct procedural service).