Gastroenterology Coding Alert

Question: Our gastroenterologist inserted a Bravo capsule over a standard pH probe on a patient to test for gastroesophageal reflux disease (GERD). Two days later, he removed the cap. The notes for the initial visit indicate that he also performed a diagnostic upper gastrointestinal endoscopy (EGD) when he inserted the pH probe. How should I report this encounter?


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Answer: In order to allow patients maximum freedom during the GERD test, a gastroenterologist may insert the Bravo cap over a standard pH probe because it cannot be seen outside the patient's body.

If the gastroenterologist inserts a Bravo capsule over a standard pH probe, you should report the visit with 91035 (Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode placement, recording, analysis and interpretation).

In your example, the operative notes also indicate that the gastroenterologist performed a diagnostic EGD, which he must do when inserting the Bravo capsule to determine how far down to place the cap.

You should report the diagnostic EGD 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])

Note: If the gastro performed a different type of EGD on the patient when he inserted the Bravo capsule, you should choose the appropriate CPT code for the EGD.
 
If, for example, the gastroenterologist took a biopsy during the EGD in the above scenario, you would report 43239 (... with biopsy, single or multiple) instead of using 43235.