No Stress EUS

No Stress EUS

Coding endoscopic ultrasound services is easy to digest if you understand the procedures and use a decision grid.

By Lynn Garrity, CPC, COC

Endoscopic ultrasound (EUS) combines endoscopy and ultrasound to obtain images of the digestive tract and the surrounding tissue and organs. The endoscopy involves inserting a long, flexible tube via the mouth to visualize the digestive tract, with or without a biopsy at the esophagus or other level. The ultrasound uses high-frequency sound waves, with or without fine needle aspiration (FNA), to produce images of the organs and structures inside the body (such as the liver, gallbladder, pancreas, and aorta). CPT® Assistant (March 2009) explains EUS “provides an advantage in the ability to image the wall of the GI tract as a series of definable layers corresponding to histology, rather than imaging the wall of the GI tract as a single entity.”

EUS allows screening for pancreatic, esophageal, and gastric cancers, and can define benign tumors of the upper gastrointestinal (GI) tract. It can also identify malformations and masses in the bile and pancreatic ducts. The gastrointestinal wall also may be imaged to see if it’s abnormally thick (which would suggest inflammation or malignancy). Payer requirements may vary, but generally EUS is considered medically necessary for:

  • Staging and/or diagnosis of cancer of the esophagus, pancreas, colon, and rectum
  • Evaluating anal incontinence
  • Evaluating abnormalities of the gastrointestinal tract wall or adjacent structures
  • Tissue sampling of lesions
  • Evaluating abnormalities of the pancreas and/or biliary tree
  • Providing endoscopic therapy under ultrasonographic guidance
  • Evaluating adenopathy and masses of the posterior mediastinum (EUS with FNA)
  • Staging of lung cancer (EUS with FNA)

CPT® codes for reporting EUS are:

43231 Esophagoscopy, flexible, transoral; with endoscopic ultrasound examination

43232 Esophagoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s)

43237 Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures

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

43242 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis)

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

CPT® Assistant (March 2009) explains, “For upper GI EUS, there are three basic components of the procedure: the endoscopic examination, the high frequency ultrasound examination, and the performance of an FNA biopsy when indicated.” To select the appropriate code, consider the individual service components documented in the patient record, and enter them into the EUS Coding Decision Grid.

EUS Coding Decision Grid

Code Esophagogastroduodenoscopy (EGD) Component Ultrasound Component FNA/Biopsy
43231 Esophagus only Esophagus only None
43232 Esophagus only Esophagus only Esophagus only
43237 Esophagus, stomach, other organs Esophagus only None
43238 Esophagus, stomach, other organs Esophagus only Esophagus only
43242 Esophagus, stomach, other organs Esophagus, stomach,  other organs Esophagus, stomach, other organs
43259 Esophagus, stomach, other organs Esophagus, stomach, other organs None

Report only a single unit of any of the above EUS codes per session. Do not report separately radiologic supervision and interpretation (e.g., 76975 Gastrointestinal endoscopic ultrasound, supervision and interpretation) or ultrasonic guidance for needle placement (e.g., 76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation), as they are inclusive of EUS procedures.

Example 1: A 39-year-old with metastatic colon cancer has a mass on the head of the pancreas, suspicious for metastatic carcinoma. EUS is performed for evaluation and placement of fiducial markers in the head of the pancreas. No biopsy is performed. Proper coding is 43259.

Example 2: EUS is performed to evaluate lymph nodes and exclude neoplasms for a 72-year-old with abdominal discomfort and multiple retroperitoneal lymph nodes. An FNA is done initially into a celiac lymph node and a biopsy is taken. Proper coding is 43242.

Example 3: A 61-year-old with cancer of the esophagus is referred for EUS. There is a stricture in the esophagus and the provider dilates the esophagus less than 15 mm in diameter. EUS FNA of a celiac lymph node is then performed. Proper coding is 43249 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter) for the EGD with balloon dilation and 43242 for the EUS FNA.


 

Lynn Garrity, CPC, COC, is a coder for Crozer Keystone Health Systems. She has 10 years’ experience with Independence Blue Cross claims adjustments, six years’ experience with HAN Billing and Promise System, and eight years’ experience in coding hospital outpatient/ancillary claims. Garrity is a member of the Upland Pennsylvania Chapter, for which she has served as CEU coordinator, treasurer, and vice president.

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