Oncology & Hematology Coding Alert

At the beginning of this year, CPT^® introduced several new codes for esophagogastroduodenoscopies (EGDs) and capsule endoscopies. But even though you have been able to use them for 12 months now, the codes are still creating problems.

So, to eliminate confusion, here are four things you should know about the new codes, along with a refresher on the different procedures and how they help diagnose cancers of the esophagus, stomach, or small intestine.

1. Know EGD v. Esophagoscopy

The first step in knowing how to document EGD and esophagoscopy procedures is knowing the difference between them. Simply put, an esophagoscopy gives a provider a view of the gastrointestinal (GI) passage between a patient’s throat and stomach. An EGD, however, looks further down the patient’s upper GI system and into the stomach and duodenum, or the first part of the small intestine.

2. Know Transnasal vs. Transoral

While you can probably guess from their names, these two different approaches involve the provider passing the esophagoscope or endoscope either through the patient’s nose or mouth. This distinction is important as a “transoral EGD is typically performed using sedation, while [a] transnasal EGD typically uses topical anesthesia,” according to CPT^® Assistant Volume 32, Issue 9 (2022). This means “the transnasal approach may be quicker and more easily tolerated by patients than traditional transoral EGD procedures, as it’s only a numbing medication in the throat and nose,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, billing specialty subject matter expert at Kareo in Irvine, California.

3. Know Your EGD T Codes

Altogether, CPT^® introduced three T codes for transnasal EGDs, effective July 1, 2021:

• 0652T (Esophagogastroduodenoscopy, flexible, transnasal; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure))
• 0653T (… with biopsy, single or multiple)
• 0654T (… with insertion of intraluminal tube or catheter)

Remember: The fifth character, T, in the code indicates the service is an emergent technology and CPT^® has assigned the procedure a temporary Category III code.

“There are currently 27 category I codes … that describe EGD via a transoral approach,” according to the CPT^® Assistant article. These services include 43235 (Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)), 43239 (… with biopsy, single or multiple), 43241 (… with insertion of intraluminal tube or catheter), and “many other transoral EGD codes that include specific additional services, such as FNA with ultrasound guidance (43238), mucosal resection (43254), lesion ablation (43270), and others,” Brame Joy says. Additional code choices could include 43210 (… with esophagogastric fundoplasty, partial or complete), 43266 (… with placement of endoscopic stent …), 43270 (… with ablation of tumor(s), polyp(s), or other lesion(s) …), and 43233 (… with dilation of esophagus with balloon …).

Coding alert: For diagnostic transnasal esophagoscopies, use 43197 (Esophagoscopy, flexible, transnasal; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)). And if your provider also performs a biopsy, CPT^® takes you to 43198 (Esophagoscopy, flexible, transnasal; with biopsy, single or multiple).

Documentation alert: There are some subtle details among these procedures, so documentation is going to make or break accurate reporting. For example, if your physician notes they went all the way through that first part of the intestine for a rigid transoral endoscopy, you’ll use a code from 43191-43196 (Esophagoscopy, rigid, transoral …).

4. Know New Capsule Endoscopy Code 91113

Another code introduced in 2022 — 91113 (Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), colon, with interpretation and report) — replaced deleted temporary code 0355T, which used the same descriptor. What’s potentially confusing about this code is its similarity to 91110 (… esophagus through ileum, with interpretation and report) and 91111 (… esophagus with interpretation and report). Which code you use depends solely on the portion of the GI tract the capsule will take images from. Pay close attention to your provider’s notes to determine which code is the most accurate and only use new code 91113 for imaging of the colon, not the esophagus.

Coding alert: If the patient is unable to swallow a capsule and the physician places it into the stomach or duodenum using endoscopic guidance, do not report 43235 (Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)) “unless the physician performs a medically reasonable and necessary complete diagnostic upper gastrointestinal endoscopy procedure,” according to Jessica Miller, CPC, CPC-P, CGIC, profee division coding manager at Ciox Health in Chattanooga, Tennessee during her recent presentation, “Ain’t Nothin’ But a Gastro Thang” at HEALTHCON Regional 2022 in Denver, Colorado.

Using modifier 52 (Reduced services) with 43235 to report placement of the capsule using EGD would not be applicable (see www.cms.gov/files/document/chapter11cptcodes90000- 99999final11.pdf). Instead, you’ll report 43235 for the EGD, and put the 52 modifier on the 91110 to indicate that the provider performed some, but not all, of that service as well.