Procedure codes and Description
• 43235 Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) b brushing or washing, when performed (separate procedure) $670.47
• 43236; with directed submucosal injection(s) any substance $670.47
• 43237; with endoscopic ultrasound examination limited to the esophagus stomach or duodenum, and adjacent structures $1,013.05
• 43238; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), esophagus (includes endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures) $1,013.05
43239 Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple
43239 with biopsy, single or multiple
GI Procedures
EGD Procedures
• Use code 43235 for a Diagnostic EGD procedure. Since this is classified as a “Separate Procedure” in the CPT book, it is not billable when a more extensive EGD procedure is performed.
• Two Upper Gastrointestinal Endoscopy procedures such as code 43239 for Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple and code 43245 for Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum, as appropriate; with dilation of gastric outlet for obstruction (e.g., balloon, guidewire, bougie) performed at the same setting would both be billable.
• If an EGD is done to collect a specimen for a CLO/H. Pylori test, since the test involves obtaining a tissue biopsy through the endoscope, the 43239 Biopsy code should be used. If the test is positive, the diagnosis code 041.86 for Helicobacter pylori (H. pylori) infection would be billed.
• If an EGD is performed with a biopsy, and then the physician removes the scope and performs an Esophageal Dilation by unguided sound, it should be billed using two CPT codes – CPT code 43239 for the scope with biopsy and code 43450 for the Esophageal Dilation would both be billed.
• Use CPT code 43248 if the patient has an EGD procedure with a flexible-tipped guidewire passed through the endoscope, the endoscope is withdrawn and the guidewire is left in place for dilators to be passed over the guidewire to dilate the Esophagus. If the guidewire is passed under fluoroscopic guidance for esophageal dilation, without the use of an endoscope, use CPT code 43453.
• The control of bleeding is included in biopsy (and most other) endoscopic procedures, and is not separately-billable. Control of bleeding can be obtained through means of injections, as well as cauterizations. Injections of Epinephrine through an endoscope are coded as 43255. This injection would be included in the ASC facility fee, and would not be reimbursed separately from the EGD procedure, unless the EGD case is completed and the patient is in the PACU and has a bleed, necessitating a return to the OR to treat the hemorrhage.
• For an EGD with a Polypectomy done by Cold Biopsy Forceps, use the 43258 Ablation code – not the 43239 Biopsy code.
Endoscopy codes
Question and Answer Forum
Question: Do codes 43239 and 43255 require modifier 59? Which do I bill first, and to which code do I attach the modifier?
Answer: If the primary purpose of the endoscopy was control of bleeding, and a separate lesion/site was found, which required biopsy, then 43255 would be reported first; 43239 with 59 modifier would be reported for the second service, which would otherwise be bundled (i.e., biopsy of the bleeding site would not be separately reportable). If bleeding resulted from biopsy of a lesion and the treatment was for this purpose, the bleeding control would be considered part of the procedure (43239) and thus, 43255 would not be separately reported.
Unbundling occurs when multiple procedure codes are submitted for a group of procedures that are described by a single comprehensive code. An example of Unbundling would be fragmenting one service into component parts and coding each component as if it were a separate service. For example, the correct CPT comprehensive code to use for upper gastrointestinal endoscopy with biopsy of stomach is CPT code 43239. Separating the service into two component parts, using CPT code 43235 for upper gastrointestinal endoscopy and CPT code 43600 for biopsy of stomach is inappropriate (per CMS National Correct Coding Policy Manual).
Q: Can we code a 43239 with a 43249? I’m not sure if 43239 is included in 43249.
A: CPT guidelines permit the reporting of multiple endoscopy codes as appropriate. Codes 43239 and 43249 describe distinctly different procedures and should not be bundled by the payers. Both codes however include an upper GI endoscopy and payment adjustments should be expected for the duplicative portion. The issue becomes one of bundling – that is, is one code “bundled” in another by the payer? With the exception of Medicare, each carrier (Cigna, Aetna, Humana, etc.) has its own edits regarding bundling. There is no “national” bundling book for us to check in other than Medicare’s Correct Coding Initiative (CCI). Under the CCI, these procedures are not bundled. I suggest that you report both services and monitor the EOB. If they are denied, I would appeal by referring to the distinct nature of the services and the CCI. It is helpful to have distinct ICD-9 codes (if appropriate) for the services to support the need for both of them on the same patient.
Upper GI Endoscopy with Biopsy CPT – 43239
Esophagogastroduodenoscopy (EGD)
The American Society for Gastrointestinal Endoscopy (ASGE) works to ensure that adequate methods are in place for gastroenterology practices to report and obtain fair and reasonable reimbursement for procedures, tests and visits. To assist practices in understanding and implementing GI-specific coding, ASGE has developed coding sheets. The purpose of the coding sheet is to provide a high-level overview to support practices in there coding and reimbursement for 2018.
What is an Esophagogastroduodenoscopy (EGD)?
It is an endoscopic procedure that visualizes the upper part of the gastrointestinal tract up to the duodenum. CPT© codes in this series (43235- 43259) identify services performed during an esophagogastroduodenoscopy.
Coding Tip – Beginning January 1, 2017, moderate sedation is no longer included in payment for gastrointestinal endoscopy services. If you provide moderate (conscious) sedation in conjunction with GI procedures you must now bill sedation separately with the appropriate moderate sedation HCPCS code(s) 99151, 99152, +99153, 99155, 99156, +99157 and G0500. This is important as the moderate sedation service was previously included in the relative value units (RVUs) for gastrointestinal endoscopy services. Failure to bill moderate sedation codes separately will result in loss of revenue for these services. ASGE suggests that you consult your individual payer policies for further information on moderate sedation billing processes.
OVERVIEW
An upper GI endoscopy (also called EGD) is a procedure that uses a lighted, flexible endoscope to see inside the upper GI tract. The upper GI tract includes the esophagus, stomach, and duodenum—the first part of the small intestine.
CLINICAL COVERAGE CRITERIA
Tufts Health plan will cover an upper GI endoscopy when ONE of the following criteria sets is met.
A. Esophageal Disease
1. Dysphagia (difficulty swallowing) or odynophagia (pain with swallowing) associated with one of the following:
a. New onset or worsening of symptoms of difficulty or pain with swallowing
b. Weight loss
c. Need for therapeutic intervention for a stricture or for achalasia
2. GERD with:
a. Persistent symptoms of GERD such as heartburn or regurgitation, AND an inadequate response to Proton-pump inhibitors (PPIs) administered for at least 4 weeks; or
b. History of GERD for one year or longer at the time of EGD request; or
c. Weight loss, anemia, abnormal radiological study of esophagus or stomach, GI bleeding, early satiety or recurrent vomiting
3. Surveillance of Members with established Barrett’s esophagus, according to intervals based on pathology:
A. High-grade dysplasia on prior biopsies: EGD with biopsy will be covered every 3 months
b. Low grade dysplasia on prior biopsies: EGD 6 months after initial biopsy and if still low grade dysplasia will be covered annually thereafter if no change in pathology
c. No dysplasia on prior biopsy: cover 2 EGDs with biopsy in one year and if normal pathology remains, every three years thereafter
4. Abnormal radiological study of esophagus or stomach
5. Esophageal varices:
a. Initial screening for esophageal or gastric varices for a Member with a diagnosis of CIRRHOSIS, regardless of liver disease etiology, as evidenced by ANY of the following:
1. Ascites
2. Bilirubin over 2.0
3. Albumin less than 3.5
4. Prothrombin Time greater than 1.7
5. Encephalopathy
6. A fibrosis score 2 or greater
b. Treatment of varices by sclerotherapy or endoscopic variceal ligation (EVL) in Members who has had documented bleeding from esophageal varices (active or in past) or;
c. For Members with high risk of esophageal variceal bleed, with no prior history of bleeding, the Member must have one or more of the following high risk factors:
1. Medium to large varices on prior screening EGD
2. Red marks such as red wale lines or red spots seen on screening or on prior EGD
3. Child’s B or C cirrhosis (significant functional compromise or decompensated liver disease)
d. Repeat screenings may be covered under the following conditions:
1. If compensated cirrhosis (stable clinically and without bleeding) and no varices on initial screen, EGD may be covered every THREE years
2. If compensated cirrhosis and varices on initial EGD, a repeat EGD will be covered every TWO years (only for Members not on beta blockers)
3. If decompensated cirrhosis (unstable clinical status) EGD may be covered ANNUALLY
6. Corrosive injuries to esophagus (unlimited)
7. Eosinophilic esophagitis (EoE) may be covered when any of the following are met:
a. Initial EGD evaluation for suspected diagnosis
b. Follow-up in 8 weeks for response to INITIAL pharmacologic treatment
c. Follow-up in 8 weeks for response to INITIAL six-food elimination diet (SFED), but NOT for subsequent surveillance with food group re-introduction, which is based on clinical response
d. For initial and re-evaluation of esophageal stricture associated with EoE
B. Anemia
1. Vitamin B-12 deficiency or;
2. Iron deficiency, defined as a documented ferritin below normal for laboratory and/or a
Fe/TIBC saturation below 20%
C. Gastric Ulcer
• Follow-up after one-two month of treatment with PPI or H-2 blocker (to confirm healing and/or rule out malignant ulcer)
D. Persistent Upper Abdominal Symptoms
1. Symptoms for at least 4 weeks (e.g., pain, nausea or vomiting) and either a. Fails to respond to maximum PPI’s (twice daily dosing) or reinstitution of PPI therapy after one successful course; or
b. Symptoms are associated with weight loss, GI bleeding, melena, anemia, anorexia or early satiety
E. Celiac Disease
1. Positive serology for celiac disease by IgA tissue transglutaminase (IgA-tTG), IgA endomysial antibody (IgA-EMA) or IgG-tTG or IgG-EMA may be substituted for Members with IgA deficiency; or
2. Any one of the following criteria:
. GI symptoms consistent with chronic malabsorption, including chronic diarrhea or
steatorrhea, abdominal distension, and weight loss; or
b. Otherwise unexplained iron, folate, or vitamin D deficiency, calcium deficiency, or secondary
hyperparathyroidism with osteoporosis or osteomalacia; or
c. In absence of other causes: persistent aminotransferase elevation, short stature, delayed
puberty, recurrent fetal loss, infertility, epilepsy or ataxia; or
d. GI symptoms, with a diagnosis of an associated high-risk conditions, such as, Type-1
Diabetes Mellitus or other autoimmune endocrinopathies (such as autoimmune thyroiditis);
first and second degree relatives with celiac disease; Turner, Down or William syndromes;
IgA deficiency, or Dermatitis herpetiformis (skin condition strongly associated with celiac
disease).
3. A repeat Upper GI Endoscopy may be covered with one of the following indications:
a. The Member fails to respond to gluten-free diet
b. Diagnosis of celiac disease is uncertain on initial testing and needs to be confirmed by rebiopsy
F. Involuntary Weight Loss
1. Weight loss of 10 pounds or more in 12 weeks or less without dietary or illness related
explanation
G. Diarrhea
When all the following criteria sets are met:
1. Greater than three weeks duration; and
2. Negative stool studies for infection, including O & P if indicated; and
3. After completion of lower bowel work-up, including flexible sigmoidoscopy or colonoscopy; and
4. For Members under 40 years old who have a history consistent with irritable bowel syndrome,
failure of fiber and anti-spasmodic to resolve diarrhea
H. Increased Risk for Gastric Cancer
When the Member has one of the following risk factors:
1. Positive diagnosis of familial adenomatous polyposis
2. Positive diagnosis of hereditary nonpolyposis colorectal cancer
3. Positive family history of gastric cancer
4. Positive diagnosis of gastric hyperplasia
CAN WE CODE 43239 AND 43248 WITH A MODIFIER 59?