Gastroenterology is a medical specialty that deals with the digestive system and its disorders. Gastroenterologists use a number of diagnostic procedures to accurately identify the patient’s medical condition and prescribe treatment. Coding for gastroenterology involves accurate coding of the various procedures and services offered by the physician. Reimbursement is offered for procedures provided in in-office, in-facility, hospital outpatient and ASC facility settings. Payment policies vary with individual payers and therefore these should be verified before providing treatment to identify limitations if any, on diagnosis, site of service or coding requirements.
Common Gastroenterology Procedures
• ERCP (endoscopic retrograde cholangiopancreatography) – this procedure combines the use of X-rays and endoscope. It is used to identify disorders such as gallstones, tumors, cysts, blockages and narrowing in the ducts.
• Sphincterotomy – to treat abnormalities diagnosed during an ERCP
• EUS (endoscopic ultrasound) – ultrasound of the pancreas, transduodenal or transgastric
• Sigmoidoscopy – enables the physician to view the lower end of the colon.
• Gastroscopy – this helps to examine the lining of the oesophagus, stomach and duodenum using an endoscope.
• Colonoscopy – is utilized by physicians to have a direct view of the whole of the large bowel or colon.
Upper Gastrointestinal Procedures and Codes
Upper gastrointestinal procedures include endoscopic and esophagoscopic procedures. These help the physician to view the interior of the upper GI tract including the esophagus, stomach and duodenum. When billing for Upper GI procedures, you have to verify payer conditions for covering the procedure. The services are usually covered when medical conditions such as esophageal disease, anemia, gastric ulcer, Celiac disease, persistent upper abdominal symptoms, and involuntary weight loss have been diagnosed.
• 43200 Diagnostic esophagoscopy
• 43202 Esophagoscopy with biopsy
• 43215 Esophagoscopy with foreign body removal
• 43216 Esophagoscopy with electrocautery removal of tumor or polyp
• 43217 Esophagoscopy with snare removal of tumor or polyp
• 43220 Esophagoscopy with dilation
• 43227 Esophagoscopy with control of bleeding
• 43232 Esophagoscopy, rigid or flexible; with transendoscopic ultrasoundguided intramural or transmural fine needle aspiration/biopsy(s)
• 43234 EGD – simple primary examination
• 43235(dagger) EGD – diagnostic
• 43238 Upper gastrointestinal endoscopy with transendoscopic ultrasoundguided intramural or transmural fine needle aspiration/biopsy(s) esophagus (includes endoscopic ultrasound examination limited to the esophagus)
• 43239(dagger) EGD with biopsy
• 43241 EGD with transendoscopic catheter or tube placement
• 43242 Upper gastrointestinal endoscopy with transendoscopic ultrasoundguided intramural or transmural fine needle aspiration/biopsy(s)(includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum and/or jejunum as appropriate)
• 43246 EGD with PEG tube placement
• 43247 EGD with foreign body removal
• 43250 EGD with electrocautery removal of tumor or polyp
• 43251 EGD with snare removal of tumor or polyp
• 43255 EGD with control of bleeding
Certain codes 43200, 43202, 43234, 43235 and 43239 require prior authorization with some payers, and this has to be verified beforehand.
Some Important Considerations
A comprehensive endoscopic evaluation of the upper GI tract has to be reported with the code 43235. This usually involves a detailed view of the esophagus, stomach and duodenum and a thorough examination of the duodenal bulb. Physicians should use code 43239 to report EGD (Esophagogastroduodenoscopy) with biopsy. An EGD that is provided just as a primary examination and does not include “comprehensive” components can be reported with the code 43234. Lesser services such as esophagoscopy and esophagoscopy with biopsy should be reported only using their specific codes, 43200 and 43202 respectively. Physicians should avoid the practice of adding modifier -52 to 43239 to signify these reduced services, because this usually results in pointless delays or even denials of payment. When reporting biopsies and procedures for removing foreign bodies, physicians should take care to choose the code that clearly specifies these.
In cases where more than one procedure is carried out during a single visit, physicians should ensure whether these come under the multiple endoscopy payment rules. Here, Medicare as well as most private payers will reimburse the full value of the highest-valued procedure, along with difference between the value of the remaining procedure and the base endoscopic procedure. Modifier -51 has to be used along with the lesser-valued procedure.