General Surgery Coding Alert

Question: A surgeon occasionally does EGD and colonoscopy at the same time on the same day. Normally, the diagnosis is rectal bleeding (569.3, hemorrhage of rectum and anus), but not always. How can we bill to get paid for both procedures?

Anonymous VT subscriber

Answer: An upper GI procedure will not be covered by a code as specific as rectal bleeding because the carrier will want to know why the surgeon performed the EGD to control bleeding in the rectum. The diagnosis code you should be using is 578.9 (hemorrhage of gastrointestinal tract, unspecified) or 578.1 (blood in stool) or the findings from the procedure, such as an ulcer code, says Karen D. Evans, RN, CPC.

Because the colonoscopy (45378, colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]) has more RVUs than the EGD (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]), the colonoscopy should be listed first.

Some Medicare carriers dont have a medical necessity policy for the EGD, but others do. Therefore, depending on your location, an inappropriate diagnosis code for the EGD could lead to the denial of the claim, says Nancy Witts, a coder with a large multispecialty practice in Arizona. All Medicare carriers have medical necessity policies for colonoscopies, she adds.

If claims are being denied, Witts says, either the diagnoses used or the physician documentation of those diagnoses needs to be re-examined, because the physician needs to show medical necessity for performing the EGD.