General Surgery Coding Alert

Question: We have an op report for a procedure described as a diagnostic EGD for gastroesophageal reflux disease (GERD) with a diagnosis of Barrett’s Esophagus, but the note states that the surgeon extended the scope past the second portion of the duodenum. Should we code this as a diagnostic enteroscopy?

Ohio Subscriber

Answer: No, you should not use the diagnostic enteroscopy 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)) for this case.

The surgeon’s stated intent and diagnostic focus is the esophagus, so you should report the diagnostic esophagogastroduodenoscopy (EGD) code 43235 (Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)).

Bottom line: 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 peek past the duodenum through the scope. However, you should steer clear of coding this as 44360 if the physician’s documentation doesn’t show that there’s a medically necessary reason.