Get a Better View of 2014 Endoscopy Changes
Understand the differences in flexible and rigid scopes and how they affect code selection.
by Shelly Cronin, CPC, CPMA, CPPM, CPC-I, CANPC, CGIC, CGSC
CPT® 2014 brought us significant changes for endoscopy coding, with new subsections and new codes. A major change was the separation of procedures performed via flexible and rigid scopes. An awareness of these changes will ensure you are coding such services correctly.
Flexible vs. Rigid Endoscopy
A rigid endoscope is a metal tube with lenses, fiber optics, or video chips to allow for image transmission, and fiber optic bundles to deliver light. Rigid endoscopes offer the best image quality and resolution of all endoscope types. A working channel found in some scopes allows the surgeon to pass instruments through, so he or she can work in real-time.
A flexible endoscope is an optical instrument with a light at the tip. It’s smooth, flexible, and approximately as big as the tip of your pinky. This flexible scope is more agile than a rigid scope, allowing the surgeon to access hard-to-reach areas. Because the lens fibers are flexible, however, images are not as clear.
All endoscopic procedure codes include bleeding control that occurs due to the procedure. Surgical endoscopy also always includes diagnostic endoscopy of the same type.
Esophagoscopy procedure codes describe examination from the cricopharyngeus muscle (upper esophageal sphincter) to, and including, the gastroesophageal junction. This includes examination of the upper stomach when the provider performs retroflexion of the scope.
The esophagoscopy subsection of CPT® includes the codes for transoral esophagoscopy procedures. These procedures belong to two distinct families, based on the use of either a rigid (43191-43196) or a flexible (43200-43232) scope. This distinction is necessary because the two types of scopes use different sedation (flexible transoral endoscopy includes moderate sedation).
For 2014, the American Medical Association (AMA) also created two new codes to indicate esophagoscopy performed via trans-nasal approach. Codes 43197 Esophagoscopy, flexible, transnasal; diagnostic, includes collection of specimen(s) by brushing or washing when performed (separate procedure) and 43198 Esophagoscopy, flexible, transnasal; with biopsy, single or multiple describe evaluation of the esophagus from its inlet to the esophagus, through the gastroesophageal junction. This includes examination of the nasal cavity (nasopharynx, hypopharynx, and larynx) on one or both sides. These new codes were necessary because of the differing techniques and the amount of work involved when performing transnasal procedures.
Esophagogastroduodenoscopy (EGD) guidelines state that if the duodenum is deliberately not examined — for example, the provider indicates it was judged not clinically pertinent to the case, or if significant situations preclude the exam — you may report the appropriate EGD code with modifier 52 Reduced services if a repeat examination is not planned, or modifier 53 Discontinued procedure. Documentation must clearly indicate why the provider did not examine the duodenum, and whether a repeat examination is planned.
New code 43211 Esophagoscopy, flexible, transoral; with endoscopic mucosal resection (found in the esophagoscopy section) describes endoscopic mucosal resection. New code 43254 Esophagogastroduodenoscopy, flexible, transoral; with endoscopic mucosal resection describes the same procedure when performed during an EGD. Do not report these codes for mucosal resection with removal of tumor(s), polyp(s), or lesion(s) by snare technique, directed submucosal injection, or band ligation of esophageal and/or gastric varices. Do not separately report biopsies performed on the same lesion(s) being removed.
Scope procedures that included stent insertions (43219, 43256, 43267, and 43268) were deleted for 2014, replaced by codes that include pre- and post-dilation of strictures with stent placement:
43212 Esophagoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)
43266 Esophagogastroduodenoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)
43274 Endoscopic retrograde cholangiopancreatography (ERCP); with placement of endoscopic stent into biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent
These codes also include placement of the guidewire, when performed.
Additional revisions for 2014 better align EGD codes with current practice descriptions. For example, code 43259 Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination, including the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis, describing endoscopic ultrasound (EUS), indicates the procedure was performed on the surgically altered stomach, where the jejunum is examined distal to the anastomosis.
Endoscopic Retrograde Cholangiopancreatography
The AMA extensively revised endoscopic retrograde cholangiopancreatography (ERCP) guidelines for 2014. Therapeutic ERCP includes diagnostic ERCP. An ERCP is considered complete if one or more ductal system(s), which includes the pancreatic and/or biliary, is visualized. You may report an attempted but unsuccessful ERCP of any ductal system using 43235-43259. This means you would not have to report modifier 52 or modifier 53 with these codes if cannulation for an ERCP was attempted, but not successful. Be sure the documentation clearly states what duct was unsuccessfully cannulated to support reporting of these codes.
The ERCP stent placement and replacement codes mirror the EGD stent placement and replacement codes; whereby, the placement or replacement includes any balloon dilation performed in that duct. If the provider performs ERCP on multiple ducts, you may report 43274 multiple times, appending modifier 59 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period to the second and subsequent units.
If ERCP includes the exchange of more than one stent during the same day/session, you may report 43276 Endoscopic retrograde cholangiopancreatography (ERCP); with removal and exchange of stent(s), biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent exchanged for the initial stent exchange, and 43276-59 for each additional, separate exchange.
Example: A patient with an existing stent in the right hepatic duct presents today for the exchange due to mechanical complication of the right stent, and the placement of a new stent in the left hepatic duct. Proper coding is 43276, 43276-59.
Specific new codes describe ERCP performed on altered postoperative anatomy (specifically for patients who have had a Billroth II gastroenterostomy). For patients who have an ERCP via a stoma, such as gastrostomy, or via Roux-en-Y anatomy, guidelines instruct you to report the appropriate unlisted code, 47999 Unlisted procedure, biliary tract or 48999 Unlisted procedure, pancreas.
A parenthetical note instructs you not to report 43277 Endoscopic retrograde cholangiopancreatography (ERCP); with trans-endoscopic balloon dilation of biliary/pancreatic duct(s) or of ampulla (sphincteroplasty), including sphincterotomy, when performed, each duct when the balloon catheter is used to clear stones or debris from a duct. Any dilation of a duct due to the passage of the catheter is considered inherent to the work described in codes 43264 and 43265. You may report 43277, however, if sphincteroplasty or dilation of a duct is required before removing the stones or debris during the same operative session.
As with the stent placement and replacement codes, you may report 43277 more than once for dilations performed on bilateral ducts, with modifier 59 appended to the second and subsequent procedure.
Shelly Cronin, CPC, CPMA, CPPM, CPC-I, CANPC, CGIC, CGSC, is AAPC’s director, eLearning Design & Enterprise Implementation. She is a member of the Salt Lake South Valley, Utah, local chapter.