Is 43239 Restricted to a Certain Number of Biopsies?
Question: I have a procedure note for an esophagogastroduodenoscopy (EGD) with a biopsy. The 45-year-old patient presented with progressive solid-food dysphagia and episodes of food impaction. The gastroenterologist performed an EGD to the second portion of the duodenum and noted the esophagus had “trachealization” and linear furrows. The provider obtained seven biopsies from the proximal and distal esophagus. The findings list “suspected eosinophilic esophagitis.” How should I code this encounter, and what does “trachealization” mean? Oklahoma Subscriber Answer: Use 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple) to report the EGD with biopsy. The provider collected seven biopsies from the patient’s esophagus, and 43239 is reserved for an EGD with one or many biopsies. Trachealization refers to when the patient develops a ringed appearance that resembles the cartilaginous rings of the trachea in the usually smooth-walled esophagus. This condition is commonly associated with eosinophilic esophagitis (EoE). As far as the diagnosis code for the encounter, you’ll assign R13.10 (Dysphagia, unspecified) to report the patient’s complaint of solid-food dysphagia that has progressed over time. You cannot use an EoE ICD-10-CM code because the gastroenterologist’s findings list it as suspected and not confirmed. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
