Gastroenterology Coding Alert

Question: Our gastroenterologist did an EGD with endomucosal resection. I am having difficulties finding a specific CPT^® code for this procedure. In the OP note it states a blue light evaluation was performed and the areas were grabbed with a band ligator followed by mucosa resection. Can you help me by letting me know what CPT^® code I should report for the procedure my gastroenterologist performed?

Minnesota Subscriber

Answer: There are no unique CPT^® codes for endomucosal resection (EMR).The removal of larger flat polyps will often include the injection of saline or other substances to help raise the polyp up making it easier to remove.  The most applicable identifiers are 43236 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed submucosal injection[s], any substance), 45381 (Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection[s], any substance), and then 43251 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique), and 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) depending on the approach used.

 If adjunctive mucosal ablation of lesion margins is used, you cannot report it with an additional code 43258 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with ablation of tumor[s], polyp[s], or other lesion[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique)and 45383 (Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor[s], polyp[s], or other lesion[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique) in addition to the polypectomy code. Since Correct Coding Initiative (CCI) edits bundle these services into the polypectomy codes, you cannot report these services together.

You can consider use of the modifier 22 (Increased procedural services)  to increase the reimbursement for the longer and more difficult procedures, but the details of how the services were more extensive than the standard procedure must be documented in a cover letter or within the report.

A center performing this procedure frequently might find it worthwhile to arrange a personal discussion between an endoscopist and the medical director of larger payers to facilitate coverage and appropriate pricing. The cost of devices used during more complicated EMR adds to the facility cost of the procedure and unfortunately it is largely without added reimbursement.