General Surgery Coding Alert

Hint: Determine how far the scope went.

According to one study, the average general surgeon performs 51 endoscopic procedures per year. This presents a challenge for coders, who have to differentiate between the rules that govern how to collect for upper gastrointestinal scope exams.

To more easily navigate the right codes to bill for these services, check out these five tips that will simplify code selection for every upper GI scope examination your providers perform.

Tip 1: Ensure Signs, Symptoms, or Disease Are Present

Upper GI scope exams can be performed for a variety of reasons, both therapeutic and diagnostic. But if you want to collect for one, you must have documentation that the provider is using the upper GI scope exam “if abnormal signs or symptoms or known disease are present,” according to the Centers for Medicare & Medicaid Services’ (CMS’) local coverage determination (LCD) L35350.

For example, the upper GI scope exam may be performed to:

• Identify anatomic abnormalities
• Evaluate symptoms
• Obtain biopsies
• Treat bleeding lesions
• Remove foreign bodies
• Place feeding tubes
• Dilate stenotic lesions
• Perform palliative therapy such as stenosing neoplasms

If, however, your general surgeon performs an upper GI scope exam for a routine screening or to evaluate uncomplicated heartburn that’s not responding well to medication, for example, most insurers will not reimburse you. “Some commercial payers have an extensive policy on indications for esophagogastroduodenoscopy (EGD) and for situations where EGD is inappropriate and will be denied or not precertified,” explains Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT® Editorial Panel advisor for the American Society for Gastrointestinal Endoscopy (ASGE) in Pasadena, California.

For that reason, it’s essential that the reason for the procedure — along with accurate ICD-10-CM codes — must be documented thoroughly in the medical record.

Tip 2: Match Code With Scope Location

Before you can fully master upper GI scope exam coding, you’ll need to become familiar with a basic checklist of which codes pair with which scope locations, as follows:

Scope limited to esophagus: Choose an esophagoscopy code from 43180-43233 to report an endoscopic examination of the esophagus even if the surgeon incidentally enters the stomach, as may happen if the physician needs to gain a retroflex view back at the cardia. You can choose options from the parent codes 43191 (Esophagoscopy, rigid, transoral; diagnostic, including collection of specimen(s) by brushing or washing when performed (separate procedure)) or 43200 (Esophagoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)).

Scope limited up to duodenum: Look to EGD codes 43235-43259, 43210, or 43270; such as base EGD code 43235 (Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)), when your general surgeon passes the pylorus with the endoscope. Even if the physician passes the pylorus and enters the jejunum due to an altered anatomy to examine the upper GI tract or after bariatric surgery, you should choose a code from the EGD (43235) family.

Scope passes second portion of duodenum: You can code for enteroscopy (44360- 44379), such as base code 44360 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)), once the scope passes at least 50 cm beyond the pylorus, per the introductory language to the section of CPT^® codes for enteroscopy. You can also find this rule in a report from the American Society for Gastrointestinal Endoscopy.

Tip 3: Don’t Use Upper GI Endoscopy Codes for Incidental Looks

Never report an upper GI endoscopy code for an incidental look beyond the duodenum. Patient charts and procedure notes are your closest allies for correctly assessing your physician’s scope and intention of endoscopy.

Focus on this: You should only report what your physician has stated as their focus or intention for the scope examination. Occasionally, a physician may take a quick look past the duodenum through the scope. However, you should steer well clear of coding this as 44360 if the physician’s documentation doesn’t show that there’s a medically necessary reason. Even the prior patient chart notes must support the surgeon’s reason for going that far.

Usually, the physician will document that their intention is to perform an EGD. Clinically, they’re just being thorough when they go beyond the second portion of the duodenum. This becomes a problem when coders report all EGDs that document “beyond the second portion of the duodenum” as enteroscopies.

In many cases, the procedure will be scheduled as a push endoscopy, and the instrument used for the procedure will either be a pediatric colonoscope or a long endoscope, not the standard upper endoscope.

Tip 4: Keep a Close Eye on NCCI

For a single procedure, you need to pick the most appropriate code from the 43235 or 44360 family. You should also get familiar with the National Correct Coding Initiative (NCCI) edits for the codes, which do not allow payment for the base EGD code (43235) with the enteroscopy code (44360) because the standard endoscopy procedure is included in the enteroscopy code by definition.

You should also avoid reporting two codes from the same family together. NCCI bundles 43235 with codes such as 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple) and 44360 with 44361 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with biopsy, single or multiple). That’s because CPT^® guidelines state that surgical/therapeutic endoscopy always includes diagnostic endoscopy.

Exception: In some cases, you’ll find a “1” modifier with the NCCI edits that allows the use of otherwise bundled codes under unusual circumstances. For example, if two different instruments were needed for two different indications, then it may be possible to bypass the NCCI edit with a modifier such as 59 (Distinct procedural service) by providing the appropriate documentation.

Tip 5: Clarify Place of Service

The place of service is a key factor in determining the endoscopy payment you recoup. Even though a push enteroscopy goes deeper, and you may think you would always get paid more for that procedure versus the EGD, that’s not always the case.

Reasoning: The AMA considers an upper endoscopy with biopsy safe to perform in the office. Therefore, your surgeon may perform the procedure in a nonfacility setting. Since there is a significant additional practice expense payment for 43239, you’ll earn more for the EGD in the office than you earn for the push enteroscopy — which is typically performed in a facility setting — even though the push enteroscopy goes farther.

The difference: Medicare pays about $155.79 for 44361 in both the facility and nonfacility settings. However, code 43239 pays just $136.48 in a facility setting but $375.48 in a nonfacility setting, based on the 2024 Medicare Physician Fee Schedule (MPFS).

Torrey Kim, Contributing Writer, Raleigh, N.C.