Gastroenterology Coding Alert

"CMS has upped RVUs for several EGD codes Do you know how frequently biopsies are performed with upper EGDs? Can you list all of the procedures included in the upper EGD family""? Become familiar with these common gastro codes to set your office up for future success." CMS Sees 43235 'Family' Frequently In the most recent list of top-50 procedures reported in gastroenterology offices the Centers for Medicare and Medicaid Service (CMS) included several codes from the 43235 endoscopy family. This is no surprise to Janene Long billing supervisor at Gastroenterology & Hepatology Associates in Reading Penn. She says the 43235 code family would have several entrants in her office's most-performed-procedures list.

Extra Incentive: These codes were always common in a gastro setting and they're also quite profitable too (see "CMS Grants RVU Increases to 5 Codes in the 43235 'Family' " ). Read on for some expert advice on the 43235 family to ensure you are coding upper diagnostic EGDs the right way every time. Learn What Makes Up a Family In order to keep things less complicated for coders and gastroenterologists CPT divides endoscopy codes into families.

Example: Rigid or flexible EGDs are grouped into one endoscopic family: The family code group starts with the base code 43200 (Esophagoscopy rigid or flexible; diagnostic with or without collection of specimen[s] by brushing or washing [separate procedure]) and includes all of the codes between 43200 and 43232 (... with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy[s]).

Families of codes share the same base procedure. "It's just that you do something else in addition [to the base procedure] " says Amanda Morreale billing supervisor for UCLA's Physician Support Services. Use 43235 as the Base Code  To best understand the 43235 family start with the base code. The 43235 family's base code is appropriately 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]) and all codes up to 43259 (... with endoscopic ultrasound examination including the esophagus stomach and either the duodenum and/or jejunum as appropriate) are part of the family.

The base code includes the diagnostic upper EGD and every other code in the family represents a procedure in which the EGD is performed in addition to something else Morreale says. Let's say the gastroenterologist performs an upper diagnostic EGD with biopsy; you would report 43239 (... with biopsy single or multiple) instead of 43235. 

Some indicators for a diagnostic EGD include:

 persistent upper abdominal distress despite trial of therapy
 upper abdominal distress with symptoms suggesting a serious organic disease such as anorexia and weight loss
 dysphagia or odynophagia
 persistent or recurrent esophageal reflux symptoms despite a trial of therapy
 persistent [...]