Sunday 8 January 2017

cpt code for egd with biopsy (CPT code 43235, 43236, 43237, 43238, 43239 - EGD codes)

Gastrointestinal bleeding:

In most actively bleeding patients. When surgical therapy is contemplated. When rebleeding occurs after acute self-limited blood loss. When portal hypertension or aorto-enteric fistula is suspected. Or, For presumed chronic blood loss and for iron deficiency anemia when colonoscopy is negative.

When sampling of duodenal or jejunal tissue or fluid is indicated. To assess acute injury after caustic agent ingestion. Or, Intraoperative EGD when necessary to clarify location or pathology of a lesion.

Indications that support EGD(s) for therapeutic purpose(s) are:

Treatment of bleeding from lesions such as ulcers, tumors, vascular malformations (e.g., electrocoagulation, heater probe, laser photocoagulation or injection therapy).

Sclerotherapy and/or band ligation for bleeding from esophageal or proximal gastric varices. Foreign body removal. Removal of selected polypoid lesions. Placement of feeding tubes (per oral, percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy). 

Dilation of stenotic lesions (e.g., with transendoscopic balloon dilators or dilating systems employing guide wires). Or, Palliative therapy of stenosing neoplasms (e.g., laser, bipolar electrocoagulation, stent placement).

LCD for Diagnostic and Therapeutic Esophagogastroduodenoscopy (L29167)

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
  
Indications and Limitations of Coverage and/or Medical Necessity

The following conditions are generally accepted as indications for the performance of EGD(s).

Indications that support EGD(s) for diagnostic purpose(s) are:

Upper abdominal distress that persists despite an appropriate trial of therapy.

Upper abdominal distress associated with symptoms and/or signs suggesting
serious organic disease (e.g., anorexia and weight loss).

Dysphagia or odynophagia.

Esophageal reflux symptoms that are persistent or recurrent despite appropriate therapy.

Persistent vomiting of unknown cause.

Other system disease in which the presence of upper GI pathology might modify other planned management. 

Examples include patients with a history of GI bleeding who are scheduled for organ transplantation, long-term anticoagulation, and chronic non-steroidal therapy for arthritis. 

Please note that this Indication does not provide coverage for routine pre-operative EGD for patients in whom bariatric surgical procedures are contemplated or planned

X-ray findings of:

A suspected neoplastic lesion for confirmation and specific histologic diagnosis.


Gastric or esophageal ulcer. Or, Evidence of upper gastrointestinal tract stricture or obstruction.

Sequential or periodic diagnostic EGD may be indicated:

For follow up of selected esophageal, gastric or stomal ulcers to demonstrate healing (frequency of follow-up EGD is variable, but every two to four months until healing is demonstrated is reasonable). 

For follow up in patients with prior adenomatous gastric polyps (approximate frequency of follow-up EGDs would be every one to four years depending on the clinical circumstances, with occasional patients with sessile polyps requiring every six months surveillance initially), and similarly with surveillance of confirmed high-grade gastric dysplasia.

For follow up for adequacy of prior sclerotherapy and/or band ligation of esophageal varices (approximate frequency of follow-up EGDs is variable depending on the state of the patient but every six to 24 months is reasonable after the initial sclerotherapy sessions are completed).

For follow-up of Barrett’s esophagus (approximate frequency of follow-up EGDs is one to two years with biopsies, unless dysplasia is demonstrated, in which case, a repeat biopsy in two to three months might be indicated).

Or,

For follow-up in patients with familial adenomatous polyposis (approximate frequency of follow-up EGDs would be every two to four years, but might be more frequent, such as every six to 12 months, if gastric adenomas or adenomas of the duodenum were demonstrated).

For follow-up of patients with severe, refractory gastroesophageal reflux disease where the concern of malignant degeneration exists (approximate frequency of every ten years)

Billing and Coding Tips

Beginning with dates of service on or after April 1, 2015, ClaimsXten removed their incidental edit on Current Procedural Terminology (CPT®) code 43235  esophagogastroduodenoscopy (EGD), flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)) when reported with CPT codes 43770-43775 (laparoscopy, surgical, gastric restrictive procedures). 

However, when an EGD is performed following a gastric restrictive  procedure to confirm there is no leakage, we consider the EGD to be an integral part of the primary procedure and not eligible for separate reimbursement. 

Therefore, beginning with claims processed on or after August 17, 2015, we will again apply the bundled services incidental edit on CPT code 43235 (EGD) when reported with CPT codes 43770-43775 (gastric restrictive procedures). This information will be documented in Section 2 of our policy.

New Codes

Balloon Dilation of Esophagus

EGD code 43233 (out of sequence) has been established to report balloon dilation of 30 mm in diameter or larger. This dilation procedure includes fluoroscopic guidance, when used.

Endoscopic Mucosal Resection

Code 43254 has been established to report endoscopic mucosal resection (EMR) with EGD. 

Code 43254 includes removal of tumor(s), polyp(s) or other lesion(s) by snare technique (43251); directed submucosal injection(s) (43236); and band ligation (43254), so these services are not separately reportable when performed on the same lesion during the same session. Biopsy (43239) performed on the same lesion as EMR is not separately reportable. 

Code 43254 includes moderate sedation, as indicated by the moderate sedation symbol.

Ultrasound-Guided Injections / Placement of Fiducial Markers

Code 43253 has been established to describe ultrasound-guided transmural injection of substances (e.g., celiac axis injection) or fiducial markers. This code includes endoscopic ultrasound (EUS) of the esophagus, stomach, and either the duodenum or a surgically-altered stomach where the jejunum is examined distal to the anastomosis. 

43239 Esophagogastroduodenoscopy, flexible, transoral; biopsy, single or multiple Parent code revised

43254 Esophagogastroduodenoscopy, flexible, transoral; EMR (endoscopic mucosal resection) New Code for 2014 Do not report biopsy 43239, submucosal injection 43236, band ligation 43244 or snare removal 43251 separately for same lesion

Key Documentation Terms

Within this area of procedures it is important to make sure that the  documentation clearly identifies what was examined and the procedure(s) performed. Codes with in this section are further classified by the procedures performed (e.g., biopsy, injection, removal of foreign body, and removal of tumor).

When reporting procedures within this family of codes, each procedure must be clearly documented. 

For instance when performing code 43250 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery, at the minimum the documentation should include what was removed and the key terms “hot biopsy forceps” or “bipolar cautery.” Code 43251 

Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique, should include what was removed and the key terms “removal of” and “snare technique” in the documentation for the procedure.

Bundling CPT 43239

Unbundling
  
Unbundling occurs when multiple procedure codes are submitted for a group of procedures that are described by a single comprehensive code.  An example of Unbundling would be fragmenting one service into component parts and coding each component as if it were a separate service. 

For example, the correct CPT comprehensive code to use for upper gastrointestinal endoscopy with biopsy of stomach is CPT code 43239.  Separating the service into two component parts, using CPT code 43235 for upper gastrointestinal endoscopy and CPT code 43600 for biopsy of stomach is inappropriate (per CMS National Correct Coding Policy Manual).

Esophagogastroduodenoscopy (EGD) CPT CODES

Revised Codes

• 43235 Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) b brushing or washing, when performed (separate procedure) $670.47

• 43236; with directed submucosal injection(s) any substance $670.47

• 43237; with endoscopic ultrasound examination limited to the esophagus stomach or duodenum, and adjacent structures $1,013.05

• 43238; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration / biopsy(s), esophagus (includes endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures) $1,013.05

• 43239; with biopsy, single or multiple $670.47

Multiple EGD and Modifier 59

Multiple EGDs? Pay Attention to Payer Guidelines and Code Order

Modifier 59 may not be part of every multi-EGD claim

To determine if your gastroenterologist merits more than one upper gastrointestinal endoscopy (EGD) CPT code for the same patient during the same encounter, you should look for biopsy details and such procedures as polyp removal and band ligation in the op notes.

When reporting multiple endoscopies from the 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate...) “family,” make sure you get the code order right. Then, you must know each of your payers’ reporting guidelines.

Bottom line: Although an upper gastrointestinal endoscopy takes a lot of time and expertise, multiple endoscopies require more of each. If you can’t report these encounters correctly, the claim may not secure your practice rightful payment for the encounter.

Know 43239: The Most Frequent Multi-EGD Code

When physicians perform multiple GI endoscopies, you’re most likely to see 43239 (... with biopsy, single or multiple) in combination with other codes from the 43245 family. In such a case, you should be sure to claim all reportable procedures to capture fully all the reimbursement your physician deserves.

“When an MD performs multiple EGD procedures in the same code set family [such as 43245 and 43239], you may submit both codes for payment,” says Susan Lariviere, CPC, MA, coder and auditor for RiverBend Medical Group in Agawam, Mass.

For example, if the gastroenterologist treats a patient for bleeding gastric ulcers, he may also take a biopsy in a separate upper GI area. When this occurs, you should: report the biopsy with 43239
use 43255 (... with control of bleeding, any method) to report the ulcer treatment
attach modifier 59 (Distinct procedural service) to 43255 to show that the biopsy and ulcer care occurred at different sites.
  
Note: Although 43255 has a higher relative value unit (RVU) than 43239, when your gastroenterologist performs 43255 and 43239 together, you should put modifier 59 on 43255. This indicates that “the biopsy wasn’t the cause of the bleed,” Rumisek says.

Other multiple EGD scenarios you may see often include EGD with biopsy with: saline or Botox injection (43236, ... with directed submucosal injection[s], any substance) removal of tumor/polyp (43250, ... with removal of tumors[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery; 43251, ... with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) band ligation of varices (43244, ... with band ligation of esophageal and/or gastric varices). Code Combos Can Vary By Office

Other coders claim the most common EGD scenario is an esophageal dilation at the same time as a biopsy at a different site.

Scenario: A patient with dysphagia and reflux symptoms reports to the office. The gastroenterologist dilates the esophagus with a balloon catheter and biopsies a separate area where he suspects Barrett’s esophagus. On the claim, you should:

report 43249 (... with balloon dilation of esophagus [less than 30 mm diameter]) for the dilation
attach ICD-9 codes 787.2 (Dysphagia) and 530.81 (Esophageal reflux) to 43249 to prove medical necessity for the dilation report 43239 for the biopsy attach ICD-9 code 530.85 (Barrett’s esophagus) to 43239 to prove medical necessity for the biopsy attach modifier 59 to 43239 to show that the biopsy was separate from the dilation. Check Payers’ Modifier Requirements, Then File

Whether you should use modifiers on your multiple EGD claim will depend on the situation. You may be tempted to slap modifier 59 on each multiple EGD claim without even thinking about it. However, if you’re not sure that every payer wants modifier 59 on a multiple EGD claim, you cannot be sure that the claim will be clean.

Consider this example: The gastroenterologist performs an upper GI EGD with biopsy and a guidewire esophageal dilation in the same session. The CPT codes for this example are always the same.

On the claim, regardless of payer, you should report:

43248 (... with insertion of guidewire followed by dilation of esophagus over guidewire) for the dilation.

43239 for the biopsy.

The modifiers you attach on this claim will depend on your payer.

Why: Many coders would likely have to attach modifier 59 to 43239. But, for some commercial payers in some states, you may have to attach modifier 59 and modifier 51 (Multiple procedures) to get this combination paid.

Important: You should apply modifier 59 only when CMS or CPT normally bundle the procedures, but you need to indicate that the physician performed those procedures at separate (and thus non-bundled) locations. “I always verify with the Correct Coding Initiative (CCI) and other carriers before adding modifier 59,” Rumisek says.

Best advice: Don’t generalize. Take the time to learn each payer’s specific rules on reporting multiple EGDs. Some payers will want you to use a combo of modifiers; others might not want to see any modifiers at all. It’s up to you to know all payer guidelines before a multiple EGD claim hits your desk.

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

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)

43236 : UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE

43237 : UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS

43238 : UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), ESOPHAGUS (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS)

43239 : UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH BIOPSY, SINGLE OR MULTIPLE

43241 : UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH TRANSENDOSCOPIC INTRALUMINAL TUBE OR CATHETER PLACEMENT 

43243 : UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH INJECTION SCLEROSIS OF ESOPHAGEAL AND/OR GASTRIC VARICES

43244 : UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH BAND LIGATION OF ESOPHAGEAL AND/OR GASTRIC VARICES

43245 : UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH DILATION OF GASTRIC OUTLET FOR OBSTRUCTION (EG, BALLOON, GUIDE WIRE, BOUGIE)

43246 : UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE

43247 : UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH REMOVAL OF FOREIGN BODY

43248 : UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH INSERTION OF GUIDE WIRE FOLLOWED BY DILATION OF ESOPHAGUS OVER GUIDE WIRE

43249 : UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)

43250 : UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY

43251 : UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE

43255 : UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH CONTROL OF BLEEDING, ANY METHOD

43258 : UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE

  

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