General Surgery Coding Alert

Question: If the surgeon performs an EGD with biopsy, and documents control of bleeding during the procedure and the highest level inpatient E/M on the same day, which services can I bill?

California Subscriber

Answer: At minimum, you should bill the EGD with biopsy as 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple). Whether you can separately bill for the bleeding control and the E/M service depends on the circumstances and your surgeon’s documentation.

Bleeding control: When bleeding occurs as a result of an endoscopic procedure, you should not separately report a code for control of bleeding during the same operative session. In other words, if the biopsy results in the bleeding that your surgeon controls, 43239 includes that work. 

However, if the surgeon documents that control of bleeding was due to the patient condition, for example, a bleeding gastric ulcer (531.01, Acute gastric ulcer with hemorrhage with obstruction), and the surgeon also takes a biopsy, you can report 43239 along with code 43255 (Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method). You’ll need to append modifier 59 (Distinct procedural service) or other appropriate modifier to override the Correct Coding Initiative (CCI) edit for these two codes.  

Evaluate E/M: Your surgeon can report a separate E/M code for the date of the EGD only if “the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual pre- and post-operative care associated with the procedure that was performed.” In that case, you’ll have to append modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same day of the Procedure or Other Service) to the appropriate E/M code, such as 99223 (Initial hospital care, per day...).