Gastroenterology Coding Alert

Question: A gastroenterologist sees a new patient complaining of frequent belching and heartburn. She performs a level-two E/M service, and subsequently, a diagnostic EGD. During the EGD, she also inserts a Bravo capsule and performs a reflux test. The test results came back negative for both cancer and gastroesophageal reflux disease (GERD). Can I report the EGD and Bravo insertion separately?

New Mexico Subscriber

Answer: Yes. You should be able to code the EGD and Bravo capsule insertion using 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic,with or without collection of specimen[s] by brushing or washing [separate procedure]), and 91035 (Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode placement, recording, analysis and interpretation), respectively.

Here's what you should report for the rest of your claim:

• 99202 -- Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making ...(for the E/M)
• modifier 25 -- Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service (appended to 99202 to show that the E/M was separate from the other procedures)
• 787.1 -- Heartburn and 787.3 (Flatulence, eructation, and gas pain) appended to 43235, 91035, and 99202 to represent the patient's symptoms.