General Surgery Coding Alert

Don't upcode incidental jejunum peek.

Not every endoscope that goes beyond the proximal duodenum warrants enteroscopy codes -- sometimes esophagogastroduodenoscopy (EGD) may be the right option despite "going the distance."

Bonus: When you code correctly by ignoring an "incidental" look to the jejunum, you just might garner a monetary reward for your general surgeon's work.

Learn Codes' Ambiguity

Look at the following codes for push enteroscopy and EGD, and you'll see that "how far" isn't the only key to these codes:

›› 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)

›› 43239 -- ... with biopsy, single or multiple

›› 44360 -- Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)

›› 44361 -- ... with biopsy, single or multiple.

Key: Although the definitions overlap regarding whether the surgeon looks beyond the duodenum to the jejunum, the codes' basis is the surgeon's focus: Is the surgeon primarily examining the upper gastrointestinal (GI) tract (esophagus and stomach) or the upper small intestine?

Conform to Surgeon's Focus

You shouldn't code an upper GI enteroscopy for an incidental look beyond the proximal duodenum.

"If an endoscope happens to be passed into the proximal jejunum during a routine upper endoscopy due to a short duodenum or altered anatomy, it does not automatically enable the use of these codes," according to The American Society for Gastrointestinal Endoscopy (ASGE) Coding Primer.

Do this: Instead, you should code the surgeon's focus. The ultimate depth that the endoscope reaches that is medically necessary will determine which endoscopy family you use to report the procedure, explains Jenny Berkshire, CPC, CGIC,CEMC, a compliance manager at Wright State Physicians in Dayton, Ohio.

Example: When the surgeon passes the pylorus with the endoscope to examine the upper GI tract prior to bariatric surgery, you should choose a code from the EGD (43235) family even if the surgeon enters the jejunum due to an altered anatomy such as a Billroth II.

Once the scope passes the second portion of the duodenum, but before passing to the ileum, you can use codes from the 44360 family -- as long as the surgeon's documentation shows medical necessity to examine the jejunum.

Caution: When you report these codes [44360 family], the surgeon typically accesses well beyond the ligament of Treitz area and well into the jejunum.

Obey Edit Limitations

For a single procedure, you need to pick the most appropriate code from the 43235 or 44360 family. "Be familiar with the Correct Coding Initiative (CCI) edits, which do not allow payment for the base EGD code (43235) with the small bowel endoscopy code (44360) because the standard endoscopy procedure is included in the small bowel endoscopy code by definition," says Michael Weinstein, MD, a physician in Washington, D.C., and former member of the AMA's CPT Advisory Panel. "The CCI edits also forbid coding 43239 with 44361."

Nor should you code together two codes from the same family -- CCI bundles 43235 with 43239 and 44360 with 44361.That's because the CPT guidelines state: "Surgical endoscopy always includes diagnostic  endoscopy," points out Amy Carroll, CGSC, coding manager at The Coding Source in Los Angeles.

Scope Type Doesn't Matter

Instead of the standard upper gastrointestinal (UGI) endoscope,surgeons sometimes use a pediatric colonoscope because its greater length allows the surgeon to reach the jejunum in a push enteroscopy. But that shouldn't change your coding.

Bottom line: "The type of scope does not determine which family of codes to use," Berkshire says.