Radiology Coding Alert

Professional coders have expressed frustration over the codes that describe radiological exams of the upper gastrointestinal (UGI) tract. For the most part, their questions focus on two series of codes, 74240-74245 (radiologic examination, gastrointestinal tract, upper) and 74246-74249 (radiological examination, gastrointestinal tract, upper, air contrast, with specific high density barium, effervescent agent, with or without glucagon). Each of these series covers distinct procedures performed under specific circumstances and easily can be confused unless the coder clearly understands the variables associated with each.

Also crucial to correct coding of these UGI exams is the documentation written in the patient record. If the radiologist doesnt clearly state the services performed and describe the contrast materials used, it will be impossible for the coder to know which code to assign.

These codes are often misrepresented, agrees Chris Sari, CPC, quality assurance manager for Advanced Radiology, which provides support to about 80 physicians, 24 freestanding facilities and eight hospitals in the Baltimore area. It is crucial that the study be clearly explained in the report and that the coder understand the specific components of the exam.

Dont Mistake Similar Procedures for UGI Studies

Coders must read the radiologists documentation carefully to ensure they dont confuse a GI study with similar exams. Because parts of the gastrointestinal anatomy are studied during a variety of procedures, it is important to identify the correct service.

For instance, although the esophagus is included in a UGI series, radiologists on occasion may perform x-ray exams of only the esophagus. This procedure would be coded CPT 74220 (radiological examination; esophagus) and would not be assigned a UGI code.

Editors note: Coders should be aware that 74220 is seldom reimbursed separately, because most third-party payers consider it a component of the UGI code.

Likewise, the small bowel often is viewed as part of a UGI study. But it also may be examined independently. In those instances, it would not be appropriate to assign any of the codes in the 74240-74249 series. Instead, coders would report 74250 (radiological examination, small bowel, includes multiple serial films) or 74251 (radiological examination, small bowel, includes multiple serial films; via enteroclysis tube).

Coders also must familiarize themselves with the conditions for which UGI studies are ordered most often. Indications for the exam may include gastritis (535.5x), duodenitis (535.6x), peptic ulcer disease (533.xx), gastric varices (456.8), neoplasms (211.0-211.9, 235.2, 235.5, 239.0, etc.) and gastric outlet obstruction (537.0). In addition, one of these studies may be ordered when patients have a history of or currently exhibit symptoms of abdominal pain, epigastric distress or discomfort, dyspepsia, nausea, vomiting, signs/symptoms of UGI bleeding, anemia and abdominal masses.

Contrast Medium Pinpoints the Series of Codes

Key to recognizing which upper GI code to assign is an understanding of the contrast materials used during the exam, Sari says, and why one may be chosen over the other. During the study, the patient is asked to swallow about 16 ounces of the contrast solution, after which the radiologist takes a series of x-ray films of the lower esophagus, stomach and duodenum.

Codes 74240-74245 generally are reported when one of two common contrast media is selected: barium sulfate or meglumine diatrizoate (Gastrografin). In most cases, the barium sulfate would be used as the medium.

But there are circumstances when use of this solution would be counterproductive or represent potential harm to the patient. For instance, if the radiologist is concerned that there may be a perforation in the gastrointestinal (GI) tract, which would allow the x-ray contrast to leak into the chest or abdominal cavity, he or she may choose to use meglumine diatrizoate, a water-soluble solution that poses virtually no health risk. Meglumine diatrizoate also may be used if the patient is at risk for vomiting or aspirating the solution, according to Kim Manion, RT, with the Flagstaff, Ariz., Medical Center.

In some cases, the water-soluble medium is used and, if no leak is identified, the radiologist may continue the study with barium sulfate. Although both solutions are used, the appropriate code from the 74240-74245 series would be reported only once.

On the other hand, series 74246-74249 is conducted with air contrast, which is produced when effervescent granules and high-density barium are consumed. According to Sari, this is called a double contrast study because both contrast agents are employed.

When this series in performed, the patient rapidly swallows carbonated powder, an effervescent agent that releases carbon dioxide into the lumen of the stomach. The carbon dioxide provides distention within the tract to facilitate the radiologists study of the gastrointestinal organs.

During a double-contrast study, the patient then ingests high-density barium, and a fluoroscope is used to visualize all segments of the lower esophagus, stomach and duodenum.

There are specific circumstances when the radiologist would choose the more typical single contrast barium study represented by the first set of codes, as opposed to an air contrast or double contrast study represented by the second set of codes, explains Manion. For instance, patients who have recently undergone surgery may not be good candidates for air contrast study, since the carbon dioxide gas may produce postoperative complications.

Specific Services Determine the Code

Once coders have identified the contrast administered and the study performed with a particular patient, they must determine which complementary services also were undertaken. Each series includes a set of three variables that must be factored into any coding scenario:

1. Whether delayed films were taken. A notation of delayed films indicates that the radiologist took additional x-rays. Radiologists often take the initial set of films immediately following the ingestion of contrast, allow an interval of time to pass, and then repeat the films to further document the flow of the medium through the UGI. Coders should note, however, that four of the six codes indicate they should be assigned with or without delayed films, which makes this distinction a moot point.

2. Whether KUB (kidneys, ureters, bladder) films were taken. KUB indicates that a single frontal x-ray of the abdominal area also was taken.

3. Whether the radiologist assessed the status of the small bowel. This typically is not included in UGI studies.

In both sets of codes, the first in the series would be assigned for the study if a KUB was not done, regardless of whether delayed films were taken.

Single contrast UGI: 74240 (radiologic examination, gastrointestinal tract, upper; with or without delayed films, without KUB)

Air/double-contrast UGI: 74246 (radiologic examination, gastrointestinal tract, upper, air contrast, with specific high-density barium, effervescent agent, with or without glucagon; with or without delayed films, without KUB)

The second in the series would be assigned for the study if a KUB was done, whether or not delayed films were taken.

Single contrast UGI: 74241 (with or without delayed films, with KUB)

Air/double-contrast UGI: 74247 (with or without delayed films, with KUB)

And the third in the series would be assigned if a small bowel follow-through was done

Single contrast UGI: 74245 (with small bowel, includes multiple serial films)

Air/double-contrast UGI: 74249 (with small bowel follow-through)