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Gastroenterology Coding Alert

EGD With EUS Evolution:

Choose From 4 Codes Now

Published on Sun Jun 12, 2005

Last year's revision to code group makes reporting EGD  with EUS more accurate

Thanks to a pair of codes previewed in CPT 2004, you can now file more accurate claims when the gastroenterologist uses endoscopic ultrasound (EUS) during an esophagogastroduodenoscopy (EGD).

Code Group Doubled in 2004

Formerly, you only had two codes to choose from when filing claims for encounters in which your gastroenterologist performed an EGD with EUS, and you had to use them no matter the extent of the physician's EUS use. But today, there are four codes to choose from, and it's possible to distinguish encounters in which the gastroenterologist only used EGD on the esophagus.

When is EUS limited to the esophagus? The gastroenterologist may use EUS only on the esophagus during an EGD when the patient has esophageal or mediastinum tumors, "particularly if there is a stricture preventing insertion to the stomach," says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the CPT Advisory Panel.

"Even if the instrument can be passed lower, there would not necessarily be any indication to use the ultrasound beyond the esophagus," Weinstein says.

Pros and cons: With a quartet of codes to choose from when reporting EGDs with EUS, coders can now report the procedure more precisely. However, the greater specificity of the codes also puts some pressure on the coder because she needs to make sure that she chooses the proper EGD-with-EUS code - or the claim will be denied.

43242, 43259 Account for EUS Past the Esophagus

Don't forget, there are two codes for EGD with EUS to indicate that the physician used EUS on the esophagus and extended EUS to the stomach or small intestine. Those codes are:

  •  43242 - Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transendoscopic ultrasound-guided 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) for EUS-guided biopsy.
  •  43259 - Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with endoscopic ultrasound examination, including the esophagus, stomach, and either the duodenum and/or jejunum as appropriate for EUS without biopsy.

    When should I use 43242 and 43259? There are several scenarios in which you would need EUS all the way to the stomach or small intestine, Weinstein says.

    "Generally, gastric ulcers, tumors, duodenal masses, strictures, pancreatic mass, pancreatic pseudocyst, or ampullary (major papilla) masses" require EUS past the esophagus, Weinstein says.

    Example: A patient with a gastric ulcerating mass meets the gastroenterologist in the endoscopic suite for an EGD. The gastroenterologist performs the EGD, using EUS on the gastric mass. On the claim, you should: 

  • report 43259 for the EGD with EUS.
     
  • attach ICD-9 code 531.9x (Gastric ulcer; unspecified as acute or chronic, without mention of hemorrhage or perforation) to represent the patient's ulcers.
        
  • attach documentation that will  fortify the claim.

    "The report should describe the procedure performed in sufficient detail to pass any post-claim audit," Weinstein says.

    Other possible diagnoses: When a gastroenterologist performs an EGD with EUS past the esophagus and into the small intestine or stomach, Weinstein says these ICD-9 codes could also prove medical necessity: 

  • 151.9 - Malignant neoplasm of stomach, unspecified
     
  • 152.x - Malignant neoplasm of small intestine, including duodenum
     
  • 157.9 - Malignant neoplasm of pancreas, part unspecified
     
  • 577.1 - Chronic pancreatitis.

    Esophagus-Only EUS? Choose From 43237, 43238

    Of course, not all EGDs require EUS past the esophagus, and CPT 2004 introduced two codes for EUS limited to the esophagus:

  •  43237 - Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with endoscopic ultrasound examination limited to the esophagus for EUS without biopsy

  •  43238 - Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), esophagus (includes endoscopic ultrasound examination limited to the esophagus) for EUS- guided biopsy.
     
    Example: The gastroenterologist sees a patient with an esophageal tumor in the endoscopy suite for an EGD. The gastroenterologist performs the EGD using EUS on the patient's esophagus only.

    On the claim, you should:
     
  •  report 43237 for the EGD with endoscopic EUS.
     
  •  attach ICD-9 code 150.9 (Malignant neoplasm of  esophagus, unspecified) to represent the patient's tumor.
     
  •  attach proper documentation to the claim. (Note: Follow the same documentation rules as you would when reporting 43242 or 43259.)

    Other possible diagnoses: Typical clinical scenarios in which a patient may need an EGD with EUS only on the esophagus would also include esophageal stricture (ICD-9 code 530.3, Diseases of esophagus; stricture and stenosis of esophagus) and Barrett's mucosa (530.85).

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