Radiology Coding Alert

Choosing the correct code to describe a diagnostic study of the upper gastrointestinal (UGI) tract presents a big challenge even to veteran radiology coders. "There are a number of possible codes that can be assigned," says Charla Prillaman, CPC, CHCO, senior coding consultant with Webster, Rogers & Co. in Florence, S.C., and the American Academy of Professional Coders (AAPC) 2000 Coder of the Year.

The source of the confusion can be found in the variables that determine which code to assign. CPT Codes provides two distinct series of codes for the studies: 74240-74245 and 74246-74249 (see box on page 26 for definitions). Both sets, Prillaman says, contain codes that describe contrast studies of the gastrointestinal tract anatomy from the patient's upper esophagus through the stomach and, in some cases, through the ileocecal valve. However, you must sort through specific elements to identify which code within the two sets of codes is most appropriate. "The radiologist's documentation is crucial when coding and billing UGI studies," she emphasizes. "The medical record must clearly state what was and/or was not done so that coders can map out the proper code."

The type(s) of contrast used during the study will help coders determine which of the two sets of codes to begin with, notes Patti Offner, RT, with Diagnostic Imaging Inc., in Philadelphia. During the study, the patient is asked to swallow about 16 ounces of positive-contrast solution, then the radiologist takes x-rays of the esophagus, stomach and duodenum. While both sets of codes describe procedures that provide images of the same anatomy, the type and combination of contrast agents determine which of the two types of codes should be reported.

Codes 74240-74245 are generally reported when one of two common contrast media is selected: barium sulfate or meglumine diatrizoate (Gastrografin). This is called a single-contrast barium study. However, sometimes the barium sulfate solution can harm the patient or provide insufficient information. In this case, the radiologist may choose to use meglumine diatrizoate, a water-soluble solution, as an alternative. Fluoroscopic visualization is performed, and documentary images are obtained.

Code series 74246-74249 is reported when effervescent granules and high-density barium are consumed. This type of study is called a "double-contrast" study because two contrast agents are employed. Radiologists may also refer to this as an "air-contrast study" in their notes because of the use of effervescent granules. Coders should be familiar with both terms to spot the type of study and choose the correct code series.

When double-contrast studies are performed, the patient rapidly swallows carbonated powder, an effervescent agent that releases carbon dioxide into the lumen of the stomach. The carbon dioxide distends the tract to facilitate the radiologist's study of the gastrointestinal organs. The patient then ingests high-density barium, and a fluoroscope is used to visualize the lower esophagus, stomach and duodenum. Documentary images are again obtained.

The water-soluble medium may initially be used and, if no leak is identified, the radiologist might continue the study with barium sulfate. Despite the fact that both solutions are used, this is considered a single-contrast study, and only a single unit of the appropriate code from the 74240-74245 series would be reported.

There are specific cases when the radiologist avoids an air- or double-contrast study and instead relies on the single-contrast test. Patients who have recently undergone surgery may not be good candidates for an air-contrast study, for example, since the carbon dioxide gas may result in postoperative complications.

Radiologists often take the initial set of films immediately following the ingestion of contrast, allow an interval of time to pass, and then repeat the films to further document the flow of the contrast material through the UGI tract. This is reflected in the medical record with a notation about delayed films. Delayed films are commonly obtained when the stomach is so spastic that the barium will not flow through. The films are taken after the spasms cease. Four of the six codes (74240, 74241, 74246, 74247) within the two series refer to these multiple images. In fact, the same codes are used whether such delayed films were obtained or not.

A notation in the medical record will indicate when anteroposterior (AP) films of the abdominal area were also taken prior to the ingestion of the contrast material. The second code in both series is assigned when this is done (i.e., 74241 and 74247) in addition to the standard UGI images.

UGI exams are often completed with images of the esophagus, stomach and duodenum. However, sometimes the small intestine or bowel distal to the duodenum is also imaged. When this occurs as part of a UGI study, the third code in each series (74245 and 74249) should be used.

Esophagus and Small Intestine Studies

"If the esophagus is imaged during a comprehensive UGI study," Prillaman says, "it is considered a component of the study and should be reported separately." Still, if the radiologist obtains images only of the esophagus, 74210 (Radiological examination; pharynx and/or cervical esophagus) or 74220 ( esophagus) may be assigned. The esophagus study codes are seldom reimbursed separately in addition to the UGI codes on the same date of service because insurers consider them a component of the comprehensive codes (74240-74249).

Although the small bowel is often viewed as part of a UGI study, it may also be examined independently. In those instances, it is not appropriate to assign any of the codes in the 74240-74249 series. Report 74250 (Radiologic examination, small intestine, includes multiple serial films) or 74251 ( via enteroclysis tube) instead, depending on the testing method used.

Diagnoses That Support Medical Necessity

A variety of ICD-9 codes are accepted by payers when 74240-74249 are reported. These include gastritis and duodenitis (535.xx add a fourth digit to identify the type of disease and the fifth digit to indicate whether the patient suffered a hemorrhage), peptic ulcer disease (533.xx additional digits specify if the disease is acute or chronic, and if a perforation or hemorrhage is indicated), esophageal varices (e.g., 456.0, Esophageal varices with bleeding) and gastric outlet conditions (e.g., 537.0, Acquired hypertrophic pyloric stenosis).

UGI studies may also be ordered when patients exhibit or have a history of a number of symptoms, including abdominal pain, epigastric distress or discomfort, dyspepsia, nausea, vomiting, signs/ symptoms of UGI bleeding, anemia and abdominal masses. Learn the local medical review policies (LMRPs) and any policies of non-Medicare payers regarding which ICD-9 codes are acceptable.