General Surgery Coding Alert

Hint: Look at the reason your surgeon is performing the injection.

When you general surgeon performs an injection during an endoscopy, you should always consider the injection part and parcel to the procedure, correct? Not necessarily -- and if you code that way, you're costing your surgeon money.

With so many options for injectable substances as well as diseases that your surgeon can treat with injections, it's essential that you know which codes are available for these injections.

You also need to be able to differentiate the codes that are specifically for sclerotherapy from other types of injections so that you're not using the wrong injection codes. Follow these five expert tips and you'll ensure you capture proper, deserved payment for every case.

1. Look for Sclerotherapy to Guide Your Coding

One common reason your surgeon would perform an endoscopy with injection is for sclerotherapy. In these cases, you should report 43204 (Esophagoscopy, rigid or flexible; with injection sclerosis of esophageal varices) or 43243 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with injection sclerosis of esophageal and/or gastric varices).

"A variety of substances can be injected into the submucosal space of the digestive tract through a sheathed needle-tipped catheter inserted through an endoscope. One of the first applications of this technique was the use of sclerotherapy to control variceal hemorrhage," explains a June 2010 CPT Assistant article. "Due to the success of sclerotherapy, endoscopists expanded their scope of injections and found that injection of nonsclerosing substances, such as diluted epinephrine and saline, was helpful in controlling bleeding from nonvariceal sources, such as peptic ulcers."

2. Decipher Upper vs. Lower Endoscopies

For endoscopy with injection that is not for sclerotherapy, you'll turn to other codes.

Option 1: If your surgeon performs an upper endoscopy with injection, you'll report one of the following codes:

• 43201 -- Esophagoscopy, rigid or flexible; with directed submucosal injection(s), any substance
• 43236 -- Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed submucosal injection(s), any substance.

According to the June CPT Assistant article, you'll report 43236 for "submucosal saline injections (as with endoscopic mucosal resection or polypectomy), botulinum toxin injection (for achalasia), India ink (for tattooing), steroid injection, or any other substance, excluding a sclerosant for esophageal/gastric varices or epinephrine to control bleeding." You'll turn to 43201 for "an endoscopy that does not include the duodenum or jejunum as part of the examination."

Option 2: If your general surgeon performs a lower endoscopy with an injection, you'll instead report one of the following codes, based on whether the physician performs a sigmoidoscopy or colonoscopy:

• 45335 -- Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance
• 45381 -- Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance.

Bottom line: "Be sure not to use the injections for sclerotherapy codes when you are injecting other substances," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program.

3. Know When to Report More Than 1 Injection Code

Most of these codes are for single or multiple injections. There may be times when you can bill for multiple injections during the same session, Bucknam says. For example, you can report 43236 multiple times if your surgeon uses different techniques on different lesions.

Modifier help: When you are able to legitimately report more than one endoscopic injection code for a session, you should use modifier 59 (Distinct procedural service).

Your surgeon's documentation should identify the lesions and the techniques he used, Bucknam cautions.

4. Don't Miss Separate Procedures

There are times when your surgeon will perform an endoscopy with injection procedure during the same session as another procedure. "These codes can often be used in conjunction with other codes as long as there is clear documentation," Bucknam explains.

Example: If your surgeon performs a polypectomy (such as 45385, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) and tattooing for subsequent resection (45381-45359) during the same session, you can report both procedures.

An example in CPT Assistant reinforces this guidance: "The base of the polyp is injected with saline (code 45381), and the polyp is then removed by snare in piecemeal fashion (code 45385). The physician then injects India ink at the polypectomy site to be able to identify the location in the future. The injection procedure would be reported with codes 45381-45359."

5. Code Control of Bleeding Separate, In Some Cases

You can separately report codes for control of bleeding if the bleeding is the reason the procedure is being performed. According to CPT Assistant when your surgeon uses injection therapy to "control hemorrhage not associated with esophageal or gastric varices," you should report on of the following codes:

• 43227 -- Esophagoscopy, rigid or flexible; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
• 43255 -- Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with control of bleeding, any method.

Caution: "If the bleeding is the result of a diagnostic or therapeutic intervention the bleeding cannot be coded separately unless it happens at a separate session," Bucknam cautions. If there is indeed a separate session and the control of bleeding is separately reportable, append modifier 59.