General Surgery Coding Alert

Question: Our surgeon performed an EGD with intention to complete a TIF procedure. Here's a portion of the note:

"The scope was advanced down the posterior pharynx into the esophagus, through the GE junction into the stomach. Retroflexion revealed that the patient appeared to have adequate amount of stomach so that the TIF could be performed. The retroflex was reversed and scope was advanced through the pylorus into the duodenum for exam. The scope was then withdrawn.

The scope was then placed through EsophyX device and advanced into the mouth via the bite block. The posterior pharynx was negotiated and the scope and the device were then advanced under direct visualization into the stomach. At this time, even with multiple manipulations, I was unable to be able to close the device safely to create the fundoplication, and the decision was made to abort the TIF."

How should I code the scenario?

New York Subscriber

Answer: Because the surgeon did not complete the transoral incisionless fundoplication (TIF), but performed only the esophagogastroduodenoscopy (EGD) in its entirety, you should report only the diagnostic EGD. In this case, the appropriate code 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]).

Because of the additional work involved in attempting the TIF, you may want to append modifier 22 (Increased procedural services) to 43235.

CPT® does not provide a distinct code for TIF. The procedure is a fundoplication done through an EGD tube, not as an open or laparoscopic procedure. If the surgeon had completed the TIF, you would report the service with an unlisted code such as 43999 (Unlisted procedure, stomach).

Billing for an unlisted discontinued service such as 43999-53 (Discontinued procedure) would probably be more difficult to justify than billing for increased services on the EGD.