Otolaryngology Coding Alert

Be prepared as T-EGD procedures filter into otolaryngology practices.

A few ENTs are venturing into territory thats patrolled mainly by gastroenterologists. Thin, flexible,fiberoptic endoscopes are bringing the stomach and small intestine into the range of the ENTs practice, for instance,when treating a patient who has gastroesophageal reflux disease (GERD), which can affect the larynx and pharynx.

Its not common for ENTs to wander so far afield, and probably wont become common. But if they do, your practice could stand to gain $279 or more so, for those rare cases, its important to know the coding.

ENTs can enter the stomach, especially to evaluate the under surface of the esophagus as it enters the stomach, says Michael Setzen MD, FACS, FAAP, chief of the Rhinology Section at North Shore University Hospital in Manhasset, N.Y., and clinical associate professor of otolaryngology at NYU School of Medicine. We can look at the stomach but thats about as far as we should go.

An advantage to transnasal esophagogastroduodenoscopy (T-EGD) over traditional endoscopy is that, in many cases, the thin scope tube that the ENT passes through the patients nose does not require sedation.

This procedure can be performed in a wider range of settings, including the clinic setting where a dedicated conscious sedation suite is not available and can be incorporated into the office visit, wrote Christopher Y.Kim, MD, and others in an article in Surgical Innovation,in 2006.

If your physicians join T-EGDs vanguard, here is a quick primer to get you up and running as you navigate unfamiliar coding territory.

Code This Typical EGD

Here are highlights of an op note typical of what you might see when your ENT performs an EGD. In this case, the ENT performed a conventional EGD with sedation, rather than using an ultrathin scope to perform a T-EGD. Regardless of approach or sedation, the coding should be the same.

Op note: Informed consent was obtained. The patient was carefully premedicated with a total of 10 mg of Versed intravenously given in careful titration prior to and during the procedure.

The adult fiberoptic gastroscope was passed into the esophagus under direct vision without complications. All areas were carefully examined. The esophagus appeared normal. The GE junction was at approximately 40 cm.There was no endoscopic evidence of Barretts esophagus. Multiple 4-quadrant biopsies were obtained. The stomach was examined next. There were superficial ulcerations of the antrum consistent with NSAID ulcerations. Multiple biopsies were obtained. The body of the stomach was normal and retroflexion showed a normal cardia and fundus. Biopsies of the antrum and body of the stomach were obtained for CLO test to assess for H. pylori. The duodenal bulb was normal and the second portion of theduodenum was also normal. The patient tolerated the procedure well without complications.

Diagnosis: In this case, the primary diagnosis is 531.90 (Gastric ulcer; unspecified as acute or chronic,without mention of hemorrhage or perforation, without mention of obstruction).

You may add V58.64 (Long-term [current] use of nonsteroidal anti-inflammatories [NSAID]) if you know from the history what medicine the patient is using.

Procedure: You should code 43239, (Upper gastrointestinal endoscopy including esophagus, stomach,and either the duodenum and/or jejunum as appropriate;with biopsy, single or multiple) says Teresa Dee Powers, CPC, CGSC, office manager for Woodburn Medical Clinic in Woodburn, Ore.

With a transitioned non-facility total RVU of 8.96,Medicares national value for 43239 is $323.15.

When coding an upper GI endoscopy, says Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Lawrenceville, Ga., you have three main questions you must answer:

1. How far did your ENT advance the scope: to the esophagus, stomach, or duodenum?

2. Did your ENT take any biopsies or remove any polyps? If so what technique did she use: cold biopsy, hot biopsy, or snare?

3. Did your ENT perform a dilation? If so, what type of dilator did your ENT use?

In order to code the base EGD procedure, 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]), your ENT must have visualized the esophagus, stomach, and either the duodenum or the jejunum. If your ENT only examines the esophagus, use procedure codes from 43200 (Esophagoscopy, rigid or flexible &) to 43234 (Upper gastrointestinal endoscopy, simple &).

In the op note, the physician clearly states she examined the esophagus, stomach, and duodenal bulb and second portion of the duodenum.

The next thing youre going to look for is what did your ENT do while scoping the patient.

In this case, the ENT examined the patient for signs of Barretts esophagus (530.85, Barretts esophagus) and took biopsies, examined the stomach and took biopsies,and examined the duodenum.

Samples: Physicians frequently collect samples of fluid or superficial tissue cells during an EGD. This is not a biopsy, and is included in the base procedure; hence the wording with or without collection of specimen(s) by brushing or washing.

Physician Collects Biopsies, Treats Polyps

Biopsies: No matter how many biopsies a physician takes during an EGD, you can only code one procedure, usually 43239 (& with biopsy, single or multiple). The only exception would be if she also performed ultrasoundguided aspiration (43238, ... with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy[s] ...) on a separate anatomical site.

Polyps: Another common procedure during an EGD is treatment of polyps or other lesions. Physicians have three codes to describe lesion removals:

" 43250 (& with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery) --An electrically charged instrument snips off a lesionand cauterizes the wound.

" 43251 (& with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) -- The physician loops a wire around the lesion or polyp to shave it off; the snare may be used with or without heat.

" 43258 (& with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique) Sometimes,the physician cant lift a lesion to snip it, so he obliterates it using, for instance, argon plasma coagulation -- a jet of ionized gas -- to coagulate the lesion.

You can only code one EGD with lesion removal unless your ENT treats different lesions with different procedures. In that case, append modifier 59 to the procedure of lesser value to break the bundle. Make sure you know which code needs modifier 59, or you could lose out on money. The modifier should always be placed on the component or Column 2 code. Otherwise, payers will deny due to CCI edits, Parks says.