Gastroenterology Coding Alert

Question: The provider performs an EGD procedure to resect an ampullary polyp. How do I code this procedure?

Nevada Subscriber

Answer: You would code for the presence of an ampullary polyp using D37.6 (Neoplasm of uncertain behavior of liver, gallbladder and bile ducts) which also includes Neoplasm of uncertain behavior of ampulla of Vater which is the site where the common bile duct joins the pancreatic duct and drains into the duodenum.

Depending on the technique for polyp removal you may report the resection with the CPT^® code 43254 (Esophagogastroduodenoscopy, flexible, transoral; with endoscopic mucosal resection) or 43251 (Esophagogas­troduodenoscopy, flexible, transoral; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique).

Remember: In 2017, these codes stand revised with removal of moderate sedation component from this procedure. Now, you will have to report the moderate sedation, using the following CPT^® codes when the same provider performs the sedation as well as the resection procedure:

• 99151 (Moderate sedation services provided by the same physician or other qualified health care profes­sional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age)
• 99152 (…patient age 5 years or older)
• +99153 (…each additional 15 minutes intraservice time [List separately in addition to code for primary service]).