General Surgery Coding Alert

Question: When our surgeon performs an EMR, we find that payment for the claims is hit or miss. Is there some specific documentation needed to use the EMR codes as opposed to another endoscopy code?

California Subscriber

Answer: Yes, there are specific steps that the op note must document for you to appropriately code an Endoscopic Mucosal Resection (EMR) procedure. When you have appropriate documentation, you should choose one of the following EMR codes based on the type of scope and portion of the digestive tract involved in the procedure:

• 43211 — Esophagoscopy, flexible, transoral; with endoscopic mucosal resection
• 43254 — Esophagogastroduodenoscopy, flexible, transoral; with endoscopic mucosal resection
• 45349 — Sigmoidoscopy, flexible; with endoscopic mucosal resection
• 45390 — Colonoscopy, flexible; with endoscopic mucosal resection

EMR involves removal of a lesion during an endoscopy using a cap or ligation technique, which includes an injection and assisted snare removal.

The injection “lifts” the tissue to be resected, creating a space below the lesion that isolates it from the underlying tissue layers. Then the surgeon uses a specialized device to remove the tissue.

To qualify as an EMR claim, you must document the following three steps clearly:

• Submucosal injection that lifts the lesion
• Clear-cut demarcation of the lesion
• Endoscopic resection of the lesion.

If your physician did not perform and document each of these steps, do not report an EMR code. Instead, based on the site and extent of tissue removal, you’ll need to report the service as a biopsy or resection, such as 43251 (Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique).

Sacrifice: If your surgeon performed an EMR but didn’t adequately document the work so that you report 43251 instead of 43254, you stand to lose $78.41 (Medicare physician fee schedule national facility amount, conversion factor 35.8043: $290.37 for 43254, $211.96 for 43251).