Elizabeth I hope you are out there.....

ckstein

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I have a question about egd documentation. My docs are good at saying that the scope was passed all the way to the duodenum, but shouldn't they be making some sort of comment on the condition? I have a report today for "iron deficiency anemia secondary to chronic blood loss, follow up of esophageal varices". Doctor inserted the scope and advanced to the 3rd part of the duodenum. His findings are "Grade I varices were found in the lower third of the esophagus." Is that enough to bill the egd? Or should I stick with a 43200?

thanks
Casey
 
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It sounds like a lazy format for the op report, but the doc did say he made it to the duodenum so your should be good with a 43235 I would think. If anyone thinks differently let me know.

Bob
 
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coachlang3

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No, the doctor only needs to show how far he/she passed the scope and document that, which he/she did.

43235 or other suitable CPT is fine.

I totally agree with Bob about the lazy format.
 
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