General Surgery Coding Alert

Question: A patient was diagnosed with sliding hiatal hernia based on X-ray findings, and our surgeon performed an EGD. We billed the service as 43270 and got a denial. What could be the reason?

Texas Subscriber

Answer: First of all, the code you mention, 43270 (Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)), is for a lesion ablation, which you did not mention. There are other codes that may be more appropriate, such as 43235 (… diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)) if the surgeon performed a diagnostic esophagogastroduodenoscopy (EGD).

Also, coverage for EGD may depend on other details and symptoms. For example, Highmark Delaware maintains a policy that includes “X-ray findings of asymptomatic or uncomplicated sliding hiatus hernia” among the indications for which the EGD is not covered.

Documentation of both symptoms and services performed with the EGD are key to appropriate coverage from your payers.