General Surgery Coding Alert

Any of more than 20 CPT codes may best describe an upper gastrointestinal (GI) procedure. Accurate coding depends on knowing exactly what the surgeon did and the final destination of the scope. Additionally, if more than one endoscopy is performed during the same session, the coder must know when HCFAs multiple-endoscopy rule applies and how payment for the operative session may be affected.

Although some upper GI procedures, such as endoscopic retrograde cholangiopancreatography (ERCP), are mainly performed by gastroenterologists, many general surgeons perform other GI endoscopic procedures, such as esophagogastroduodenoscopy (EGD), percutaneous endoscopic gastrostomy (PEG) tube placement, biopsies and lesion removals.

The base code for this endoscopic family is 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]), which should be used when the surgeon performs a diagnostic EGD. Other procedures performed with an EGD include biopsy (43239), placement of PEG tube (43246, see story this issue), removal of foreign body (43247), dilation of esophagus with (43248) and without (43249) guide wire, removal of lesion by hot biopsy forceps (43250) or snare (43251) techniques, ablation of lesion (43258) and control of bleeding (43255).

Because there are so many variations of the upper GI endoscopy, documentation must clearly describe the service. Further, if a lesion is removed, the method (hot biopsy forceps, snare or ablation) should also be indicated in the procedure notes, as well as at the top of the operative report.

Choosing Esophagoscopy or Upper GI Endoscopy

If specific landmarks are not reached during the scope, the procedure may not qualify as an upper GI scope and may need to be billed as an esophagoscopy.

CPT lists 12 esophagoscopy codes, many of which parallel the upper GI codes (biopsy, foreign body and lesion removal, for example). To further complicate matters, an EGD includes work, such as lesion removal, in the esophagus.

CPT does not include gastroscopy codes. If the endoscope passes the esophagogastric (EG) junction into the stomach but is not moved beyond the pylorus into the duodenum (or jejunum, in some cases), only an esophagoscopy may be billed.

If, for example, while removing an esophageal lesion by snare, the surgeon moved the scope past the EG junction into the stomach but did not go as far as the pylorus, 43217 (esophagoscopy, rigid or flexible; with removal of tumor[s], polyp[s] or other lesion[s] by snare technique) should be used. However, if an esophageal lesion is removed but the scope crossed the pyloric valve into the duodenum (and the medical necessity for doing so is documented), an EGD was performed and 43251 (upper gastrointestinal endoscopy ... with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) should be billed.

Although surgeons typically explore the duodenum when performing a diagnostic upper GI scope, that is not always the case. For example, notes Tray Dunaway, MD, FACS, a general surgeon in private practice in Camden, S.C., the endoscope may be placed in the stomach, which is full of food. Because of the increased risk of aspiration, the surgeon may remove the scope without moving beyond the pylorus.

Frequently, however, surgeons do explore the duodenum when performing gastroscopy, unless prevented from doing so by the patients condition (for example, an obstructed pyloric valve or a full stomach). However, there must also be a documented medical reason for moving the scope beyond the pylorus.

For example, if the patient has gastrointestinal bleeding of any kind, the surgeon may need to explore the entire upper GI tract to locate the source of bleeding. In this case, 43235 appropriately describes the procedure as long as the surgeon documents the abdominal bleeding.

Multiple Endoscopy Rule Applies

Patients often require more than one upper GI scope. For example, while performing an EGD (43235), the surgeon also may take a biopsy (43239) and remove a lesion by hot forceps technique (43250).

Codes 43239 and 43250 are payable as long as different procedures are performed at different sites. The different site does not have to be in another section of the stomach, duodenum or esophagus; a separation as small as 1 centimeter constitutes a separate site.

Because the biopsy and polyp removal are from the same endoscopic family (i.e., both are upper GI procedures, not esophagoscopies or colonoscopies, for example), normal multiple-procedure rules do not apply. Instead, billing for these procedures is guided by Medicares multiple-endoscopy rule, which states, For multiple endoscopic procedures, use the full value of the highest valued endoscopy plus the difference between the next highest and the base endoscopy.

This means that 43250 would be listed first, followed by 43239. Although the EGD (43235) is not listed because it is bundled to both of the other procedures (the edit includes a 0 indicator, meaning no override is possible), it remains an important factor in determining the correct billing amount because it is the base code for this family of endoscopic procedures. The calculation is as follows: The highest-paying procedure is 43250 with 5.40 relative value units (RVUs). This amount is added to the difference between the next highest procedure, 43239, and the base code, 43235 (4.59 - 4.11 = 0.48). The total value of the scope procedures, therefore, is 5.88 RVUs (5.40 + 0.48).

Although 43250 and 43239 are not bundled in the national Correct Coding Initiative (version 7.1), modifier -59 (distinct procedural service) should be appended to the lesser procedure (43239) to indicate that the procedures were performed on different sites.

When billing most local Medicare carriers, modifier -51 (multiple procedures) should not be attached to procedures within the same endoscopic family because doing so may result in a further fee reduction. Some payers may not be guided by this HCFA policy, however, and it is best to contact your carrier and obtain a predetermination of payment when multiple endoscopies are performed.

Note: In the unlikely event that an esophagoscopy and upper GI endoscopy are performed at the same time, the multiple-endoscopy rule does not apply because the procedures are in different endoscopic families.

Supply Proper Documentation

Many general surgeons select codes from a charge sheet, or charge ticket, that lists a multitude of procedures, including upper GI endoscopies. But regardless of how familiar the surgeon is with the procedure codes, the operative report still needs to be reviewed, says Jan Rasmussen, CPC, a general surgery coding and reimbursement specialist in Eau Claire, Wis.

Even knowledgeable physicians may not keep up on coding and billing policies that change regularly. I dont expect them to know Medicares definition of a complication, or global package and multiple procedure guidelines, she says. In any event, having something written down other than the charge ticket is preferable.

Clear and accurate documentation is particularly important if more than one scope is performed and modifier -59 is appended to the second scope procedure to indicate it was performed at a separate location. In such cases, documentation needs to indicate clearly the different sites to support the separate claims.

Similarly, if an EGD was performed but esophageal or stomach lesions or varices were treated, the reason for extending the scope past the pylorus should be noted, preferably in a Findings section of the operative report. This section should explain, in short and simple terms, what the surgeon found, what he or she did and why he or she did it.