General Surgery Coding Alert

Question: Last week, a patient presented with diarrhea and anemia. The surgeon performed an endoscopy and took a biopsy of the duodenum to rule out celiac disease. Should I report an upper gastro endoscopy code, or do payers consider this procedure a small intestinal endoscopy?


Ohio Subscriber

Answer: The answer depends on what type of scope your surgeon used during the procedure.

Before sending out the claim, make sure you double-check your coding with the surgeon. You can, however, look at the operative report for clues as to what type of endoscopy took place.

Examine the procedure notes and check for a scope type. If the surgeon used a pediatric colonoscope or dedicated push enteroscope, this usually indicates a small intestinal endoscopy, in which case you would:
 

report 44361 (Small intestinal endoscopy,  enteroscopy beyond second portion of duodenum, not including ileum; with biopsy, single or multiple) to describe the procedure
 

attach ICD-9 codes 787.91 (Diarrhea) and 783.21 (Loss of weight) to 44361.

If the surgeon used a standard endoscope, however, she is probably performing an upper GI endoscopy, in which case you would:
 

report 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple) for the procedure
 

attach ICD-9 codes 787.91 and 783.21 to 43239.