take a look inside this egd for correct cpt® coding

7/26/2019 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 The scope was withdrawn and the procedure terminated.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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Contact Us:Name: Sam Nair

Title: Associate Director

Email: [email protected]

Direct: 704 303 8150

Desk: 866 228 9252, Ext: 4813

The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713









take a look inside this egd for correct cpt® coding

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