Take a Look Inside This EGD for Correct CPT® Coding
Transcript of Take a Look Inside This EGD for Correct CPT® Coding
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Take a Look Inside This EGD for Correct CPT® Coding
By Susan Dooley
If you’ve been in the healthcare profession for a while, chances are you know that EGD is the
abbreviation for esophagogastroduodenoscopy. This long and intimidating word simply means to view
the esophagus, stomach, and first part of the small intestine (duodenum) with a scope. Learn to choose
the right upper endoscopy code by analyzing this EGD procedure note.
PROCEDURE PERFORMED: EGD With Biopsy.
Following a thorough discussion of the risks and benefits of the proposed procedure, the patient
willingly gave consent to undergo the procedure. She was laid supine on the table in the endoscopy
suite and carefully premedicated with a total of 5 mg of Versed intravenously given prior to and during
the procedure. The fiberoptic gastroscope was passed into the esophagus through the oral cavity under
direct vision without complications. The esophagus was examined and appeared normal, with no clinical
evidence of Barrett’s esophagus. Multiple biopsies were obtained of the esophagus. The
gastroesophageal junction was at 40 cm from the incisor teeth. Upon entering the stomach, superficial
ulcerations of the antrum were noted, consistent with ulcerations from nonsteroidal antiinflammatory
drug usage. Multiple biopsies were obtained of the stomach in the area of the ulcerations. The body of
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the stomach was normal. On retroflexion of the scope, the cardia and fundus appeared normal. Biopsies
were taken of the antrum and body to assess for the presence of H. pylori. The scope was passed into
the duodenum, and the duodenal bulb appeared normal. The second portion of the duodenum also
appeared normal. The scope was withdrawn and the procedure terminated. The patient tolerated the
procedure well.
Consider Three Factors to Code an Upper GI Endoscopy
When coding for an upper GI endoscopy, consider these factors:
1.
How far did the gastroenterologist advance the scope? Did she stop at the esophagus
(esophagoscopy) or go all the way to the duodenum (an EGD)?
2.
Did she perform biopsies or remove polyps? If so, what technique was used, such as cold or hot
biopsy forceps, or a snare?
3.
If dilation was performed, what type of dilator was used?
Correctly Code This EGD
In this report, no dilation was performed, nor were any polyps removed. However, biopsies were taken
of the esophagus and stomach. The gastroenterologist did advance the scope all the way into the
second portion of the duodenum.
In view of this, you would report this procedure with this CPT® code:
43239, Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple.
You’ll need to report a primary diagnosis, also. In this patient’s case, here’s the one to use:
K25.9, Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation.
Our example operative note gave no information on the patient’s history of NSAID use, though it’spossible that information was in the patient’s H&P or in notes from an office visit. If you knew this
patient had a history of taking nonsteroidal antiinflammatory drugs, then you’d include this secondary
diagnosis:
Z79.1, Long term (current) use of non-steroidal anti-inflammatories (NSAID).
Was Enteroscopy Performed?
Enter/o is the combining form for intestine, so from looking at the procedure name of
esophagogastroduodenoscopy, you might assume you could code an enteroscopy instead of an EGD for
this procedure. But enteroscopy, often called push enteroscopy, is a separate procedurethat is less
commonly performed than is EGD.
To be considered enteroscopy, the physician must advance the scope beyond the second portion of the
duodenum, up to the jejunum. There must be medical necessity to visually examine the distal
duodenum or proximal jejunum, however, such as GI bleeding of obscure origin, surveillance for
polyposis in that region, or suspected neoplasm of the jejunum. In such cases the procedure will likely
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be scheduled as a push enteroscopy, not as an EGD. In such a case, a code such as this one may be
appropriate:
44361, Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not
including ileum; with biopsy, single or multiple.
Sometimes gastroenterologists will perform an EGD and happen to advance the scope beyond the
second portion of the duodenum. This cannot be coded as an enteroscopy; instead, code as an EGD as
noted above. According to the American Society for Gastrointestinal Endoscopy (ASGE) Coding Primer: A
Guide for Gastroenterologists, incidental passage of a scope into the proximal jejunum during a routine
upper endoscopy because of a short duodenum or surgically altered anatomy does not automatically
enable the use of an enteroscopy code.
What About You?
I find push enteroscopy fascinating, but I run across it infrequently compared to regular endoscopy. How
about you? Let us know your experience in the comment box below.
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