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Clinical Policy Title: Upper gastrointestinal endoscopy

Clinical Policy Number: 08.01.13

Effective Date: August 1, 2018

Initial Review Date: June 5, 2018

Most Recent Review Date: July 3, 2018

Next Review Date: July 2019

Related policies:

CP# 08.01.01 Capsule endoscopy

CP# 08.01.11 Gastroparesis evaluations

ABOUT THIS POLICY: Select Health of South Carolina has developed clinical policies to assist with making coverage determinations. Select

Health of South Carolina’s clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of “medically necessary,” and the specific facts of the particular situation are considered by Select Health of South Carolina when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. Select Health of South Carolina’s clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. Select Health of South Carolina’s clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, Select Health of South Carolina will update its clinical policies as necessary. Select Health of South Carolina’s clinical policies are not guarantees of payment.

Coverage policy

Select Health of South Carolina considers the use of upper gastrointestinal endoscopy to be clinically

proven and, therefore, medically necessary when any of the following criteria are met (Cohen, 2006;

Early, 2012; Hirota, 2006):

For diagnostic purposes, in the following situations:

Persistent upper abdominal distress despite an appropriate trial of therapy.

Upper abdominal distress associated with signs or symptoms suggestive of serious organic

disease (such as weight loss and prolonged anorexia) or in members over age 45.

Dysphagia or odynophagia of unknown cause.

New onset of dyspepsia in members age 50 and older.

Persistent or recurrent esophageal reflux signs or symptoms despite appropriate therapy.

Persistent vomiting of unknown cause.

Postoperative bariatric surgery with persistent nausea, vomiting, or abdominal distress despite

counseling and behavior modification regarding diet.

Policy contains:

Esophagogastroduodenoscopy.

Upper endoscopy.

Gastroscopy.

Gastroesophageal reflux

disease.

Hematemesis.

Gastrointestinal bleeding.

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Presence of systemic disease, the treatment of which would potentially be modified based on

upper gastrointestinal pathology. Examples include patients with a history of gastrointestinal

bleeding who are scheduled for organ transplantation; long-term anticoagulation; chronic

nonsteroidal therapy for arthritis; or with cancer of the head or neck.

Findings on X-ray of any of the following:

A suspected neoplasm, for confirmation and biopsy for histology.

Esophageal or gastric ulcer.

Evidence of upper gastrointestinal tract obstruction or stricture.

Presence of gastrointestinal bleeding, under any of the following conditions:

When bleeding is active or recent.

When surgical therapy is under consideration.

When portal hypertension or aorto-enteric fistula is suspected.

For presumed chronic blood loss and for iron deficiency anemia when colonoscopy

findings are negative.

When the sampling of tissue or fluid is indicated.

After caustic agent ingestion, to assess acute injury.

During surgery, to identify the location or clarify the pathology of a lesion or to evaluate

anatomic reconstructions.

In members with a familial adenomatous polyposis syndrome.

To evaluate potential upper gastrointestinal role in suspected lower gastrointestinal disorders

such as celiac disease or in pediatric inflammatory bowel disease.

For therapeutic purposes, in any of the following conditions:

To treat bleeding from lesions including ulcers, tumors, vascular malformations (for example,

electrocoagulation, heater probe, injection therapy, or laser photocoagulation).

To perform sclerotherapy for bleeding from esophageal or proximal gastric varices or banding of

varices.

To remove a foreign body.

To remove selected polypoid or submucosal lesions.

For placement of feeding tubes (oral, percutaneous endoscopy gastrostomy, percutaneous

endoscopic jejunostomy).

For dilation of stenotic lesions (e.g., with dilating systems employing guidewires or with

transendoscopic balloon dilators).

To provide palliative therapy of stenosing neoplasms (such as laser, stent placement, and bipolar

electrocoagulation).

For management of gastroduodenal dysmotility when symptoms persist despite optimal medical

and dietary management.

For treatment of achalasia.

For dilation in adult members with eosinophilic esophagitis who have a dominant esophageal

stricture or ring and remain symptomatic despite medical therapy.

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Endoscopic resection for members with Barrett’s esophagus, in the absence of life-limiting

comorbidities, is medically necessary with any of the following findings:

Low-grade dysplasia.

Flat high-grade dysplasia.

Intestinal metaplasia.

Endoscopic resection or radiofrequency ablation for members without life-limiting comorbidities

and stage T1a esophageal adenocarcinoma.

Screening (periodic diagnostic) upper gastrointestinal endoscopy may be indicated for a medically

appropriate number of procedures in the following active or symptomatic conditions:

For follow up of members with portal hypertension or compensated cirrhosis if any of the

following criteria are met:

Finding of small varices and high-risk stigmata, follow-up every one to two years.

With no finding of varices, follow up every two to three years.

In members with history of alcohol abuse or decompensated liver disease, follow-up

annually.

For follow up of selected esophageal, gastric, or stomal ulcers to demonstrate healing. The

frequency of follow-up examinations is variable, but every two to four months until healing is

demonstrated is reasonable.

For follow up in members with prior adenomatous gastric polyps. The approximate frequency of

follow-up examinations would be every one to four years, depending on the clinical

circumstances. Some members with sessile polyps would initially require surveillance every six

months initially).

For follow up for adequacy of prior sclerotherapy or banding of esophageal varices. The

approximate frequency of follow-up procedures varies widely depending on the state of the

member. Every six to 24 months is reasonable after completion of the initial

sclerotherapy/banding sessions have been completed.

For follow up of Barrett's esophagus, approximately every one to two years with biopsies, unless

dysplasia or atypia is demonstrated, in which case a repeat biopsy in two to three months may

be indicated.

For follow up in members with familial adenomatous polyposis, the recommended approximate

frequency of follow up is every two to four years. However, the presence of gastric adenomas or

adenomas of the duodenum may indicate more frequent follow up of every six to 12 months.

Limitations:

Upper gastrointestinal endoscopy is not medically necessary for the following:

Screening of asymptomatic upper gastrointestinal tracts of members at average risk.

Follow-up screening for Barrett’s esophagus after the previous examination findings were

negative for Barrett’s esophagus.

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Screening for aerodigestive cancer.

Follow-up of any of the following:

Healed benign disease, such as gastric or duodenal ulcer, or esophagitis.

Gastric atrophy.

Pernicious anemia.

Fundic gland or hyperplastic polyps.

After radiographic findings of any of the following:

Sliding hiatal hernia, asymptomatic or uncomplicated.

Uncomplicated duodenal ulcer that has responded to treatment.

Deformed duodenal bulb in the absence of symptoms or when symptoms respond to

ulcer therapy.

Confirming eradication of Helicobacter pylori eradication.

To evaluate isolated pylorospasm, known congenital hypertrophic pyloric stenosis, constipation and encopresis, or inflammatory bowel disease responding to therapy.

Prior to bariatric or non-gastroesophageal surgery in asymptomatic individuals.

Metastatic adenocarcinoma of unknown primary site when the results will not alter management.

To obtain tissue samples from endoscopically normal tissue to diagnose reflux disease or exclude Barrett’s esophagus in adults.

To evaluate symptoms considered functional in origin.

To evaluate benign-appearing, uncomplicated duodenal ulcers identified on radiologic imaging.

When there is clinical evidence of acute perforation.

Upper gastrointestinal endoscopy is contraindicated in conditions including shock, peritonitis, fulminant

colitis, perforated viscus (e.g., esophagus, stomach, intestine), acute myocardial infarction (unless there

is an active life-threatening hemorrhage), and severe cardiac decompensation. Additionally, relative

contraindications include individuals who are not fully conscious, alert, and cooperative, and who have

cardiac arrhythmias or recent myocardial ischemia (Chan, 2017).

Alternative covered services:

X-ray.

Ultrasound.

Capsule endoscopy.

Ambulatory esophageal pH monitoring.

Background

Upper gastrointestinal endoscopy, also known as esophagogastroduodenoscopy, upper endoscopy, or

gastroscopy, is a procedure in which a flexible tube known as a fiberoptic endoscope, which may have

video capacity, is introduced into the upper gastrointestinal system (National Institute of Diabetes and

Digestive and Kidney Diseases, 2017). This transmits a magnified image that is used to examine tissue,

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visualize the area while extracting biopsies, or perform a therapeutic procedure. The areas that can be

visualized during the procedure are the esophagus, stomach, and upper intestine (duodenum). The

procedure can be performed on an outpatient basis, usually while a patient is sedated. It is generally a

brief procedure lasting 15 to 30 minutes. The risks from the procedure, which are considered low,

include bleeding, perforation of the lining of the upper gastrointestinal tract, and a reaction to the

sedative.

Gastrointestinal endoscopy is a keystone of the evaluation and management of gastrointestinal disease

(Sivak, 2006). Upper gastrointestinal endoscopy is used to identify the causes of symptoms such as

abdominal pain or bleeding, discomfort eating or swallowing, heartburn, nausea, vomiting, and

indigestion. Upper gastrointestinal endoscopy is useful in diagnosing conditions including esophagitis,

Schatzki’s ring (lower esophageal ring or esophagastric ring), inflammation of the stomach or

duodenum, ulcer, polyps, diverticula, and other abnormalities — including mucosal tears, obstructions,

strictures, and tumors. The procedure can also be used therapeutically to treat conditions such as

bleeding due to ulcers, to remove foreign objects, polyps, or growths, to widen strictures with a small

balloon, and to place feeding tubes. In addition, the procedure is used to screen for possible disease in

symptomatic individuals or individuals at risk for gastrointestinal disease, and to follow up on treated

conditions.

Searches

Select Health of South Carolina searched PubMed and the databases of:

UK National Health Services Centre for Reviews and Dissemination.

Agency for Healthcare Research and Quality’s National Guideline Clearinghouse and other

evidence-based practice centers.

The Centers for Medicare & Medicaid Services.

We conducted searches on April 30, 2018. Search terms were: “upper gastrointestinal endoscopy,”

“esophagogastroduodenoscopy,” “upper endoscopy,” and “gastroscopy.”

We included:

Systematic reviews, which pool results from multiple studies to achieve larger sample sizes

and greater precision of effect estimation than in smaller primary studies. Systematic

reviews use predetermined transparent methods to minimize bias, effectively treating the

review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies.

Guidelines based on systematic reviews.

Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple

cost studies), reporting both costs and outcomes — sometimes referred to as efficiency

studies — which also rank near the top of evidence hierarchies.

Findings

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We were unable to identify many publications on the comparative efficacy of upper gastrointestinal

endoscopy for the multiple indications for which it is commonly used, or on safety of the procedure. The

coverage indications for this policy are based on several professional guidelines, primarily developed by

the American Society of Gastrointestinal Endoscopists. Their publication on the indications for

gastrointestinal endoscopy (Early, 2012) is the main source for the coverage policy, along with earlier

publications on quality indicators (Cohen, 2006) and premalignant conditions (Hirota, 2006).

The need for effective screening and diagnostic tools evolve as disease trends shift. Increases in obesity

and gastroestophageal reflux disease are provoking some shifts in how upper gastrointestinal

endoscopy is used. Upper gastrointestinal endoscopy is of limited value in diagnosing gastroesophageal

reflux disease. Instead, ambulatory esophageal pH monitoring is more sensitive since it estimates distal

esophageal acid exposure and can show the relationship between acid reflux and its symptoms.

A cost-effectiveness analysis examined the clinical and economic impact of performing upper

gastrointestinal endoscopies in patients with indications suggesting they should have the procedure in

comparison with those without an indication for the procedure (DiGiulio, 2009). The results showed

that to detect one case of cancer among those with appropriate indications, 41 procedures had to be

performed, while 753 had to be performed in those without an indication in order to find one case of

cancer. To prevent one death related to gastroesophageal cancer, 571 procedures had to be carried out

in those with indications, while 11,111 procedures had to be carried out in those without indications for

the procedure. Per life-year gained, the incremental cost-effectiveness ratios of appropriate and

inappropriate upper endoscopies, as compared to a policy of not referring patients for endoscopy, were

$16,577 in those with an indication for the procedure and $301,203 in those without an indication for

the procedure. This analysis does not take into account the risk of procedures in those without an

indication.

Policy updates:

None.

Summary of clinical evidence:

Citation Content, Methods, Recommendations

Pimenta-Melo (2016)

Missing rate for gastric

cancer

Key points:

A total of 22 studies were included in this meta-analysis.

The pooled negative predictive value was 99.7% (95% confidence interval 99.6-99.9%).

The missed gastric cancer proportion was 9.4% (95% confidence interval 5.7 – 13.1%),

and was 10.0% in studies including patients with negative findings followed over time.

The proportion was 8.3% in studies including patients with gastric cancer, and 23.3% in

studies evaluating the proportion of missed synchronous lesions.

Missed cancers were mainly located in the gastric body and most were

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Citation Content, Methods, Recommendations

adenocarcinomas. Predictors of diagnostic failure were younger age (<55 years), female

sex, marked gastric atrophy, gastric adenoma or ulcer, and inadequate number of

biopsy fragments.

The authors conclude that upper gastrointestinal endoscopy is a very effective method

to rule out gastric cancer, but that one in 10 cancers are potentially missed.

Interestingly, lesions were more often missed in the body and, therefore, a more

rigorous protocol for endoscopy and biopsy should be implemented worldwide.

American Society for

Gastrointestinal Endoscopy

(2014)

Endoscopy in evaluation

and management of

dysphagia

Key points:

Endoscopy is indicated in patients with dysphagia to determine the underlying etiology,

exclude malignant and premalignant conditions, assess the need for therapy, and

perform therapy, such as dilation.

Esophageal dilation is a therapeutic procedure performed for the management of

dysphagia. The primary indication for dilation is to provide immediate and durable

symptomatic relief of dysphagia.

Safety and efficacy have been confirmed in both adults and the pediatric population.

Ford (2010)

Prevalence of clinically

significant endoscopic

findings in dyspepsia

Key points:

This systematic review and meta-analysis identified 151 publications that reported the

prevalence of dyspepsia. Of these, nine reported prevalence of endoscopic findings

among 5,389 total participants.

Erosive esophagitis was the most common abnormality encountered (pooled prevalence

13.4%) followed by peptic ulcer (pooled prevalence 8.0%). The only finding encountered

more frequently in individuals with dyspepsia, compared with those without, was peptic

ulcer (odds ratio, 2.07; 95% confidence interval, 1.52-2.82). The prevalence of erosive

esophagitis was lower when the Rome criteria were used to define dyspepsia compared

with a broad definition (6% versus 20%).

Erosive esophagitis was the most common finding encountered at endoscopy for

dyspepsia. The prevalence was lower when the Rome criteria were used to define

dyspepsia. Only peptic ulcer was found to be more common in individuals with

dyspepsia.

DiGiulio (2009)

Cost-effectiveness of upper

gastrointestinal endoscopy

according to

appropriateness of the

indication

Key points:

The authors constructed a decision analysis model to compare a strategy of not referring patients for upper endoscopy (with either an appropriate or inappropriate indication) with a policy of carrying out the requested upper endoscopy. Cancer prevalence in appropriate and inappropriate procedures was estimated using a systematic review of the literature. Costs of the procedure and cancer care were estimated from Medicare reimbursement data.

The number of appropriate and inappropriate procedures required to detect one case of cancer was 41 and 753, respectively. To prevent one gastroesophageal cancer-related death, the numbers were 571 and 11,111, respectively.

The incremental cost-effectiveness ratios of appropriate and inappropriate upper endoscopies as compared to a policy of not referring patients for endoscopy were $16,577 and $301,203, respectively, per life-year gained.

The authors conclude that for inappropriate upper endoscopies, the very low likelihood of cancer and the relatively high costs associated with this procedure argue against endoscopic referral.

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References

Professional society guidelines/other:

American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee. The role of

endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc. 2010 Jan;71(1):1-9.

doi: 10.1016/j.gie.2009.09.041.

ASGE Standards of Practice Committee, Pasha SF, Acosta RD, et al. The role of endoscopy in the evaluation and management of dysphagia. Gastrointest Endosc. 2014;79(2):191-201. Chan, WW. Endoscopy. Merck Manual Professional Version. Updated February, 2017. https://www.merckmanuals.com/professional/gastrointestinal-disorders/diagnostic-and-therapeutic-gi-procedures/endoscopy. Accessed April 30, 2018. Cohen J, Safdi MA, Deal SE, et al. Quality indicators for esophagogastroduodenoscopy. Gastrointest

Endosc. 2006;63(4):S10-S15.

Early DS, Ben-Menachem T, Decker GA, et al. Appropriate use of GI endoscopy. Gastrointest Endosc. 2012;75(6):1127-1131.

Faigel DO, Pike IM, Baron TH, et al. Quality indicators for gastrointestinal endoscopic procedures: an

introduction. Gastrointest Endosc. 2006;63(4):S3-S9.

Hirota WK, Zuckerman MJ, Adler DG, et al; Standards of Practice Committee, American Society for Gastrointestinal Endoscopy. ASGE guideline: The role of endoscopy in the surveillance of premalignant conditions of the upper GI tract. Gastrointest Endosc. 2006;63(4):570-580. National Institute of Diabetes and Digestive and Kidney Diseases. Upper GI endoscopy. National

Institutes of Health website. July, 2017. https://www.niddk.nih.gov/health-information/diagnostic-

tests/upper-gi-endoscopy. Accessed April 30, 2018.

Spechler SJ, Sharma P, Souza RF, Inadomi JM, Shaheen NJ. American Gastroenterological Association

Technical Review on the Management of Barrett’s Esophagus. Gastroenterology. 2011;140(3):e18-e13.

doi:10.1053/j.gastro.2011.01.031.

Peer-reviewed references:

Cena M, Gomez J, Alyousef T, Trohman RG, Pierko K, Agarwal R. Safety of endoscopic procedures after

acute myocardial infarction: a systematic review. Cardiol J. 2012;19(5):447-452.

Di Giulio E, Hassan C, Pickhardt PJ, et al. Cost-effectiveness of upper gastrointestinal endoscopy

according to the appropriateness of the indication. Scand J Gastroenterol. 2009;44(4):491-498.

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Ford AC, Marwaha A, Lim A, Moayyedi P. What is the prevalence of clinically significant endoscopic

findings in subjects with dyspepsia? Systematic review and meta-analysis. Clin Gastroenterol Hepatol.

2010;8(10):830-837, 837.e831-832.

Kwan V. Advances in gastrointestinal endoscopy. Internal medicine journal. 2012;42(2):116-126.

Sivak MV. Gastrointestinal endoscopy: past and future. Gut. 2006;55(8):1061-1064.

CMS National Coverage Determinations (NCDs):

100.2 Endoscopy. Longstanding national coverage determination, the effective date of which has not

been published. https://www.cms.gov/medicare-coverage-database/details/ncd-

details.aspx?NCDId=81&ncdver=1&CoverageSelection=National&KeyWord=endoscopy&KeyWordLookU

p=Title&KeyWordSearchType=And&bc=gAAAACAAAAAA&. Accessed April 30, 2018.

Local Coverage Determinations (LCDs):

L35350 Upper gastrointestinal endoscopy (diagnostic and therapeutic). Revision effective date October

1, 2017. https://www.cms.gov/medicare-coverage-database/details/lcd-

details.aspx?LCDId=35350&ver=36&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&

KeyWord=upper+gastrointestinal+endoscopy&KeyWordLookUp=Title&KeyWordSearchType=And&bc=g

AAAACAAAAAA&. Accessed April 30, 2018.

L34434 Upper gastrointestinal endoscopy and visualization. Revision effective date February 26, 2018.

https://www.cms.gov/medicare-coverage-database/details/lcd-

details.aspx?LCDId=34434&ver=37&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&

KeyWord=upper+gastrointestinal+endoscopy&KeyWordLookUp=Title&KeyWordSearchType=And&bc=g

AAAACAAAAAA&. Accessed April 30, 2018.

InterQual

LOC: Acute adult. InterQual 2017. All categories. Anemia/bleeding.

LOC: Acute adult. InterQual 2017. All categories. General medical.

CP: Procedures. InterQual 2017. Specialized procedures. Endoscopy, upper gastrointestinal.

CP: Procedures. InterQual 2017. Specialized procedures. Endoscopy, upper gastrointestinal (pediatric).

Commonly submitted codes

Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is

not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and

bill accordingly.

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CPT Code Description Comments

43191 Esophagoscopy rigid trnso dx

43192 Esophagoscp rig trnso inject

43193 Esophagoscp rig trnso biopsy

43194 Esophagoscp rig trnso rem fb

43195 Esophagoscopy rigid balloon

43196 Esophagoscp guide wire dilat

43197 Esophagoscopy flex dx brush

43198 Esophagosc flex trnsn biopsy

43200 Esophagoscopy, flexible, transoral; diagnostic, including collection of specimen(s)

by brushing or washing, when performed (separate procedure)

43201 Esoph scope w/submucous inj

43202 Esophagoscopy, flexible, transoral; with biopsy, single or multiple

43204 Esoph scope w/sclerosis inj

43205 Esophagus endoscopy/ligation

43206 Esoph optical endomicroscopy

43210 Egd esophagogastrc fndoplsty

43211 Esophagoscop mucosal resect

43212 Esophagoscop stent placement

43213 Esophagoscopy retro balloon

43214 Esophagosc dilate balloon 30

43215 Esophagoscopy flex remove fb

43216 Esophagoscopy lesion removal

43217 Esophagoscopy snare les remv

43220 Esophagoscopy balloon <30mm

43226 Esoph endoscopy dilation

43227 Esophagoscopy control bleed

43229 Esophagoscopy lesion ablate

43231 Esophagoscop ultrasound exam

43232 Esophagoscopy w/us needle bx

43233 Egd balloon dil esoph30 mm/>

43235 Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection

of specimen(s) by brushing or washing, when performed (separate procedure)

43236 Uppr gi scope w/submuc inj

43237

Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound

examination limited to the esophagus, stomach or duodenum, and adjacent

structures

43238

Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic

ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s),

(includes endoscopic ultrasound examination limited to the esophagus, stomach or

duodenum, and adjacent structures)

43239 Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple

43240 Egd w/transmural drain cyst

43241 Egd tube/cath insertion

43242 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic

ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s)

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CPT Code Description Comments

(includes endoscopic ultrasound examination of the esophagus, stomach, and

either the duodenum or a surgically altered stomach where the jejunum is

examined distal to the anastomosis)

43243 Egd injection varices

43244 Egd varices ligation

43245 Egd dilate stricture

43246 Egd place gastrostomy tube

43247 Egd remove foreign body

43248 Egd guide wire insertion

43249 Esoph egd dilation <30 mm

43250 Egd cautery tumor polyp

43251 Egd remove lesion snare

43252 Egd optical endomicroscopy

43253 Egd us transmural injxn/mark

43254 Egd endo mucosal resection

43255 Egd control bleeding any

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

43260 Ercp w/specimen collection

43261 Endo cholangiopancreatograph

43262 Endo cholangiopancreatograph

43263 Ercp sphincter pressure meas

43264 Ercp remove duct calculi

43265 Ercp lithotripsy calculi

43266 Egd endoscopic stent place

43270 Egd lesion ablation

43274 Ercp duct stent placement

43275 Ercp remove forgn body duct

43276 Ercp stent exchange w/dilate

43277 Ercp ea duct/ampulla dilate

43278 Ercp lesion ablate w/dilate

74235 Remove esophagus obstruction

ICD-10 Code Description Comments

C15.3-C17.9 Malignant neoplasm of esophagus, stomach, small intestines

C32.0-C33 Malignant neoplasm of larynx and trachea

D51.0 Vitamin B12 deficiency anemia due to intrinsic factor deficiency

K21.9 Gastro-hyphenesophageal reflux disease without esophagitis

K22.70-

K22.719 Barrett's esophagus

C81.01-

C81.03

Nodular lymphocyte predominant Hodgkin lymphoma involving lymph nodes of

head, face, neck, intrathoracic and intra-hyphenabdominal

C81.11-

C81.13

Nodular sclerosis classical Hodgkin lymphoma involving lymph nodes of head,

face, neck, intrathoracic and intra-hyphenabdominal

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ICD-10 Code Description Comments

C81.21-

C81.23

Mixed cellularity classical Hodgkin lymphoma involving lymph nodes of head, face,

neck, intrathoracic and intra-hyphenabdominal

C81.31-

C81.33

Lymphocyte-hyphendepleted classical Hodgkin lymphoma involving lymph nodes

of head, face, neck, intrathoracic and intra-hyphenabdominal

C81.41-

C84.43

Lymphocyte-hyphenrich classical Hodgkin lymphoma involving lymph nodes of

head, face, neck, intrathoracic and intra-hyphenabdominal

C81.71-

C81.73

Other classical Hodgkin lymphoma involving lymph nodes of head, face, neck,

intrathoracic and intra-hyphenabdominal

C81.91-

C81.93

Hodgkin lymphoma, unspecified, involving lymph nodes of head, face, neck,

intrathoracic and intra-hyphenabdominal

C82.01-03,

C82.11-13,

C82.21-23,

C82.31-33,

C82.41-43,

C82.51-53,

C82.61-63,

C82.81-83,

C82.91-93

Follicular lymphoma involving lymph nodes of head, face, neck, intrathoracic and

intra-hyphenabdominal

C83.01-

C83.03

Small cell B-hyphencell lymphoma involving lymph nodes of head, face, neck,

intrathoracic and intra-hyphenabdominal

C83.11-

C83.13

Mantle cell lymphoma involving lymph nodes of head, face, neck, intrathoracic and

intra-hyphenabdominal

C83.31-

C83.33

Diffuse large B-hyphencell lymphoma involving lymph nodes of head, face, neck,

intrathoracic and intra-hyphenabdominal

C83.51-

C81.53

Lymphoblastic (diffuse) lymphoma involving lymph nodes of head, face, neck,

intrathoracic and intra-hyphenabdominal

C83.71-

C83.73

Burkitt lymphoma involving lymph nodes of head, face, neck, intrathoracic and

intra-hyphenabdominal

C83.81-

C83.83

Other non-hyphenfollicular lymphoma involving lymph nodes of head, face, neck,

intrathoracic and intra-hyphenabdominal

C83.91-

C83.93

Non-hyphenfollicular (diffuse) lymphoma involving lymph nodes of head, face,

neck, intrathoracic and intra-hyphenabdominal

C84.01-

C84.03

Mycosis fungoides involving lymph nodes of head, face, neck, intrathoracic and

intra-hyphenabdominal

C84.41 Mycosis fungoides involving lymph nodes of head, face, neck, intrathoracic and

intra-hyphenabdominal

C84.61-

C84.63,

C84.71-

C84.73

Anaplastic large cell lymphoma involving lymph nodes of head, face, neck,

intrathoracic and intra-hyphenabdominal

C84.a1-

C84.a3

Cutaneous T-hyphencell lymphoma, unspecified, involving lymph nodes of head,

face, neck, intrathoracic and intra-hyphenabdominal

C85.11-

C85.13

Unspecified B-hyphencell lymphoma involving lymph nodes of head, face, neck,

intrathoracic and intra-hyphenabdominal

C85.21-

C85.23

Mediastinal (thymic) large B-hyphencell lymphoma involving lymph nodes of head,

face, neck, intrathoracic and intra-hyphenabdominal

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ICD-10 Code Description Comments

C85.81-

C85.83

Other specified types of non-hyphenHodgkin lymphoma involving lymph nodes of

head, face, neck, intrathoracic and intra-hyphenabdominal

C85.91-

C85.93

Non-hyphenHodgkin lymphoma, unspecified, involving lymph nodes of head, face,

neck, intrathoracic and intra-hyphenabdominal

C86.0, C86.2-

C86.3 Other specified types of T/NK-hyphencell lymphoma

C91.40-

C91.42 Hairy cell leukemia

C96.20-

C96.29 Malignant mast cell tumor

C96.a Histiocytic sarcoma

C96.z Other specified malignant neoplasms of lymphoid, hematopoietic and related

tissue

C96.9 Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified

D12.0-D12.6 Benign neoplasm of colon

D13.0-D13.39 Benign neoplasm of esophagus, stomach, duodenum and of other and unspecified

parts of small intestine

D37.8-D37.9 Neoplasm of uncertain behavior of other specified and unspecified digestive

organs

D50.0-D50.9 Iron deficiency anemia

D62 Acute posthemorrhagic anemia

I50.00-I50.11 Esophageal varices

K20.0-K21.0 Esophagitis

K21.9 Gastro-hyphenesophageal reflux disease without esophagitis

K22.10-

K22.11 Ulcer of esophagus

K22.3 Perforation of esophagus

K22.5 Diverticulum of esophagus, acquired

K22.70-

K22.719 Barrett's esophagus

K25.0-K25.9 Gastric ulcer

K26.0-K26.9 Duodenal ulcer

K27.0-K27.9 Peptic ulcer

K28.0-K28.9 Gastrojejunal ulcer

K30 Functional dyspepsia

K31.7 Polyp of stomach and duodenum

K76.6 Portal hypertension

K92.0-K92.2 Hematemesis, melena and unspecified gastrointestinal hemorrhage

Q26.6 Portal vein-hyphenhepatic artery fistula

R10.11-

R10.12 Pain localized to upper abdomen, right and left upper quadrant

R10.13-

R10.33 Epigastric and periumbilical pain

R11.10 Vomiting, unspecified

R13.0-R13.19 Aphagia and dysphagia

R93.3 Abnormal findings on diagnostic imaging of other parts of digestive tract

14

ICD-10 Code Description Comments

R93.5 Abnormal findings on diagnostic imaging of other abdominal regions, including

retroperitoneum

T54.0x1+-

T54.94x+ Toxic effect of corrosive substances [acute injury after caustic ingestion]

T57.1x1+-

T57.1x4+ Toxic effect of phosphorus and its compounds [acute injury after caustic ingestion]

HCPCS

Level II Code Description Comments

N/A Not Applicable