Upper EUS no EGD scope used

[judebrianna44@gmail.com]

Hi, in the instance that your provider does not indicate that a separate EGD scope was used in addition to the EUS scope how would you bill for this procedure? I have been billing 43259, 52.

My provider is adamant that the use of only EUS scope is sufficient in satisfying the needs of the reported code 43259. Any knowledge on this topic would be greatly appreciated!

 

[tkermode]

The code description for 43259 indicates a separate EGD is required, that is what the semi-colon convention in CPT means. Base procedure; with other service performed.

43259 - Esophagogastroduodenoscopy, flexible, transoral;
with endoscopic ultrasound examination, including the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis

Here's the common Language Procedure description from Decision Health:

The mouth and throat are numbed using an anesthetic spray. A hollow mouthpiece is placed in the mouth. The flexible fiberoptic endoscope is inserted and advanced as it is swallowed by the patient. Once the endoscope has been advanced beyond the cricopharyngeal region, it is guided using direct visualization. The esophagus is inspected and any abnormalities are noted. The endoscope is then advanced into the stomach and the stomach is insufflated with air. The cardia, fundus, greater and lesser curvature, and antrum of the stomach are inspected and any abnormalities noted. The tip of the endoscope is passed through the pylorus into the duodenum or into the jejunum in the case of a surgically altered stomach where the jejunum is examined distal to the anastomosis. The mucosal surfaces are inspected. The scope is then withdrawn and the entire circumference of the duodenum or jejunum (where the stomach has been surgically altered), stomach, and esophagus are again examined.
Following endoscopic examination, an echoendoscope is introduced and any abnormalities or lesions are again carefully evaluated. Ultrasound images are obtained to determine whether the abnormality or lesion is intrinsic (within) or extrinsic (outside) the upper gastrointestinal tract. If the lesion is intrinsic, it is evaluated to determine whether it is limited to the mucosa or involves the muscular wall. If it is extrinsic, it is evaluated to determine whether it is in the mediastinal space or has invaded the mediastinal wall, what thoracic organs are involved, and whether there is any lymph node involvement. If it is in the stomach or small intestines, the lesion is evaluated in the same manner to determine whether invasion is limited to the peritoneal cavity or whether other sites and/or structures are involved. Hard copies of ultrasound images are made and the abnormalities are again evaluated.

And here's the CPT Lay Terms Description:

The physician uses an endoscope to examine the upper gastrointestinal tract and performs an endoscopic ultrasound examination of the esophagus, stomach, and the duodenum and/or jejunum. The physician passes an endoscope through the patient's mouth into the esophagus. The esophagus, stomach, duodenum, and sometimes the jejunum, are viewed. The endoscope may be removed and a radial scanning echoendoscope inserted or an ultrasound probe is passed through the already placed endoscope and an ultrasound examination is performed, including the esophagus, stomach, and the duodenum and/or jejunum. The echoendoscope or ultrasound probe is fitted with a water-filled balloon near the tip, which contains a transducer that picks up the ultrasound frequency and relays it to a processor outside of the body, where the internal images can be viewed on screen. When the ultrasound scanning is completed, the instruments are removed.

It's clear from these descriptions that the service includes a scope portion and an ultrasound portion. Remember, the guidance in CPT is also coding guidelines, so this info from CPT should be sufficient foundation to support the need for an EGD portion, should your provider say, "Who says so?"