Part B Insider (Multispecialty) Coding Alert

Published on Wed Jun 15, 2011 PDF

Question: My gastroenterologist wants me to bill photo documentation along with an EGD. Can I bill for photo documentation? What CPT® should I use?

Answer: You cannot bill for photo documentation, only for the appropriate EGD procedure (i.e., 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]). When physicians take pictures during an EGD, you should consider the photo documentation part of the diagnostic procedure. Other supplies and services you should deem part of a surgical procedure include:

• cleansing, shaving, and prepping of skin;
• draping of patient, positioning of patient;
• insertion of intravenous access for medication;
• sedative administration by the physician performing the procedure;
• local, topical or regional anesthetic administered by the physician performing the procedure;
• surgical approach, including identification of anatomical landmarks, incision, evaluation of the surgical field, lysis of simple adhesions, isolation of neurovascular, muscular (including stimulation for identification), bony or other structures limiting access to the surgical field preoperative, intraoperative and postoperative documentation, including photographs, drawings, dictation, transcription;
• surgical supplies, unless excepted by policy.