Gastroenterology Coding Alert

Check out expert tips on how to scour the documentation.

Ten months after their integration into the code set at the beginning of this year, several codes continue to give GI coders trouble. If you’re still puzzled when it comes to coding peroral endoscopic myotomy (POEM), T codes for transnasal esophagogastroduodenoscopy (EGD), or other common endoscopic procedures, this refresher course may come in handy.

Read on for explanations about how to distinguish among similar codes and tips for what kinds of details to look for in the patient record.

Pay Attention to new POEM Code 43497

AMA added 43497 (Lower esophageal myotomy, transoral (ie, peroral endoscopic myotomy [POEM])) to the CPT^® code set in 2022, but nuances of the code may still confuse your coding. “For a while, that was the biggest gripe we all had:

We didn’t have a CPT^® code for POEMs. Well, now we do have one,” said Jessica Miller, CPC, CPC-P, CGIC, profee division coding manager at Ciox Health in Chattanooga, Tennessee during her recent presentation on recent GI coding changes and challenges, “Ain’t Nothin’ But a Gastro Thang” at HEALTHCON Regional 2022 in Denver, Colorado.

The procedure: During a POEM procedure, which is performed to treat achalasia, the gastroenterologist uses a scope to make an incision in the mid-esophagus and then dissect through the submucosal space and dissect muscle fibers of the lower esophageal sphincter muscle. “The incision is closed sometimes with clips or endoscopic suturing, and the procedure is similar to what was performed as a ‘Heller myotomy’ by surgeons before the endoscopy technique was developed,” says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel member in Pasadena, California. Gastroenterology coders used to report POEM with code 43499 (Unlisted procedure, esophagus), which is still the code to use when reporting G-POEM procedures.

Understand the difference between POEM and G-POEM: Remembering that POEM and G-POEM are not the same procedure and therefore are coded differently is important.

“G-POEM is a procedure in which the physician relaxes the pylorus. That’s the valve between the stomach and small bowel,” said Miller. When that valve isn’t working properly, it won’t allow food and drink to pass freely and can cause bloating, nausea, vomiting, and reflux. “G-POEM is done entirely through endoscopy and can be used to treat achalasia and gastro paresis, but is still an unlisted procedure, coded to 43499,” explained Miller.

Consider New Capsule Endoscopy Code 91113

Remember that code 91113 (Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), colon, with interpretation and report) recently replaced deleted code 0355T of the same descriptor. What’s potentially confusing about this code is its similarity to 91110 (Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus through ileum, with interpretation and report) and 91111 (Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus with interpretation and report). Which code you use depends solely on the specific capsule used and the portion of the GI tract the capsule will take images from. Pay close attention to the gastroenterologist’s notes to determine which code is the most accurate. As noted in the code descriptor, you should use new code 91113 for imaging of the colon, not the esophagus.

Coding alert: If the patient is unable to swallow a capsule and the physician places it into the stomach or duodenum using endoscopic guidance, do not report 43235 (Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)) “unless the physician performs a medically reasonable and necessary complete diagnostic upper gastrointestinal endoscopy procedure,” said Miller. Using modifier 52 (Reduced services) with 43235 under those circumstances would be applicable, but requires submitting careful documentation to the payer to explain rationale and detail.

Propel Your EGD T-Code Prowess

The three 2022 T-codes for transnasal esophagogastroduodenoscopy (EGD) are also regularly causing confusion among coders:

• 0652T (Esophagogastroduodenoscopy, flexible, transnasal; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure))
• 0653T (… with biopsy, single or multiple)
• 0654T (… with insertion of intraluminal tube or catheter)

These codes are used for transnasal diagnostics that involve passing the endoscope through the patient’s nose, down into the esophagus, into the stomach, and into the first part of the intestine.

Coding alert: These T-codes are not for coding diagnostic transnasal esophagoscopies. For that procedure, use 43197 (Esophagoscopy, flexible, transnasal; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)), not a new T code. And if your provider also performs a biopsy, CPT^® takes you to 43198 (Esophagoscopy, flexible, transnasal; with biopsy, single or multiple).

Documentation alert: There are some subtle details among these procedures, so documentation is going to make or break accurate reporting. For example, your physicians need to note that they went all the way through that first part of the intestine. “Additionally, if their notes show they went through that first part of the intestine but the described procedure outlines rigid transoral endoscopy, those details mean you’ll code between 43191 and 43197,” said Miller.