Esophagogastroduodenoscopy CPT code full list
CPT Code Code Descriptor Change Detail
*43235 Esophagogastroduodenoscopy, flexible, transoral; diagnostic includes brushing or washing when performed Terminology reconciliation
*43236 Esophagogastroduodenoscopy, flexible, transoral; directed submucosal injection Parent code revised Not separately reported during injection of varices,
endoscopic mucosal resection or control of bleeding described by 43243, 43254 or 43255, for same lesion.
*43237 Esophagogastroduodenoscopy, flexible, transoral; EUS limited to esophagus, stomach OR duodenum Parent code revised Utilized when the endoscopy is complete EGD for visualization but EUS service is limited to one or two regions of esophagus, stomach or duodenum (or jejunum via surgically altered stomach).
*43238 Esophagogastroduodenoscopy, flexible, transoral; EUS with FNA limited to esophagus, stomach OR duodenum Parent code revised Includes EUS 43237. Report when EGD is complete but EUS, FNA is confined to 1 or 2 regions of esophagus, stomach or duodenum (or jejunum via surgically altered stomach).
*43239 Esophagogastroduodenoscopy, flexible, transoral; biopsy, single or multiple Parent code revised
*43240 Esophagogastroduodenoscopy, flexible, transoral; transmural drainage, pseudocyst Parent code revised Includes placement of drainage, stents, transmural needle
aspiration and EUS during the same session
*43241 Esophagogastroduodenoscopy, flexible, transoral; intraluminal tube or catheter insertion Parent code revised Do not report 43241 in conjunction with stent placement 43266
*43242 Esophagogastroduodenoscopy, flexible, transoral; EUS with FNA of esophagus, stomach AND duodenum Parent code revised Utilized when the endoscopy is complete EGD for visualization and EUS visualization is performed in all regions. FNA may be performed in 1 or more regions. Report once per session.
*43243 Esophagogastroduodenoscopy, flexible, transoral; injection sclerosis of esophageal/ gastric varices Parent code revised Do not separately report 43236 submucosal injection or 43255 control of bleeding for same lesion.
*43244 Esophagogastroduodenoscopy, flexible, transoral; band ligation of esophageal/ gastric varices Parent code revised Band ligation as part of snare polypectomy during EMR 43254 is not separately reported
*43245 Esophagogastroduodenoscopy, flexible, transoral; dilation of gastric/duodenal stricture(s) Parent code revised Utilized to report dilation of gastric outlet, native or post-op (e.g., gastro-jejunal bypass) Dilation codes are not separately reportable with tumor ablation or stent placement described by 43266, 43270
Report fluoroscopy with 74360, when performed by endoscopist
*43246 Esophagogastroduodenoscopy, flexible, transoral; place gastrostomy tube Parent code revised
*43247 Esophagogastroduodenoscopy, flexible, transoral; foreign body removal Parent code revised
*43248 Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire rather than
Esophagogastroduodenoscopy, flexible, transoral; guide wire insertion Parent code revised 43248 is not reported with stent placement or ablation codes described by 43266, 43270 Report fluoroscopy with 74360, when performed by endoscopist
*43249 Esophagogastroduodenoscopy, flexible, transoral; transendoscopic balloon dilation of esophagus (<30 mm) Parent code revised 43249 is not separately reportable with stent placement or ablation code described by 43266, 43270 Report fluoroscopy with 74360, when performed by endoscopist
*43233 Esophagogastroduodenoscopy, flexible, transoral; dilation of esophagus with balloon (30 mm or larger) New Code for 2014 (e.g., achalasia therapy)
Includes fluoroscopic guidance, when performed
*43250 Esophagogastroduodenoscopy, flexible, transoral; removal of tumor(s), polyp(s) or other lesion(s) by hot biopsy or bipolar cautery Parent code revised
*43251 Esophagogastroduodenoscopy, flexible, transoral; snare lesion removal Parent code revised Not separately reportable with endoscopic mucosal resection described by 43254, for same lesion
*43252 Esophagogastroduodenoscopy, flexible, transoral; optical endomicroscopy Parent code revised
*43253 Esophagogastroduodenoscopy, flexible, transoral; EUS-guided transmural injection New Code for 2014 (e.g., celiac axis neurolysis, fiducial marker placement)
Not separately reportable with ultrasound described by 43237, 43238, 43242, 43259, 76942, 76975 or with pseudocyst drainage described by 43240
*43254 Esophagogastroduodenoscopy, flexible, transoral; EMR (endoscopic mucosal resection) New Code for 2014 Do not report biopsy 43239, submucosal injection 43236, band ligation 43244 or snare removal 43251 separately for same lesion
*43255 Esophagogastroduodenoscopy, flexible, transoral; control of bleeding, any method Parent code revised See 43243 or 43244 for varices treatment. Do not report
43236 injection for bleeding treatment of same lesion, although can be reported for tattoo of lesion site if separately needed (59 modifier). Do not report if bleeding is caused by endoscopic procedure.43256 with transendoscopic stent placement (includes predilation) (43256 has been deleted. To report, use 43266) Deleted 43256
Use 43266
*43266 Esophagogastroduodenoscopy, flexible, transoral; stent placement New Code for 2014 Includes dilation and guide wire passage, when performed. Report fluoroscopy with 74360, when performed by endoscopist
*43257 Esophagogastroduodenoscopy, flexible, transoral; thermal energy to LES and/or cardia, for GERD Parent code revised 43258 with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique Deleted 43258 Use 43270
*43270 Esophagogastroduodenoscopy, flexible, transoral; ablation of tumor(s), polyp(s) or other lesion(s) New Code for 2014 Includes dilation, guide wire passage when performed
*43259 Esophagogastroduodenoscopy, flexible, transoral; EUS of esophagus, stomach AND duodenum Parent code revised Not separately reportable with pseudocyst drainage 43240 or injection of substance(s) described by 43253 Utilized when the endoscopy is complete EGD for visualization and EUS visualization is performed in all
Esophagogastroduodenoscopy (EGD) Codes – (43235 – 43259)
CPT codes 43235-43259 have been placed in the new EGD subsection. These codes have been revised to describe flexible transoral EGD and include five new codes, revision and renumbering of several existing codes and the deletion of two codes. Additionally, the following qualification to the definition of EGD has been included in the new EGD Guideline language to clarify the appropriate use of modifiers -52 and -53:
To report esophagogastroscopy where the duodenum is deliberately not examined [e.g., judged clinically not pertinent], or because significant situations preclude such exam [e.g., significant gastric retention precludes safe exam of duodenum], append modifier 52 if repeat examination is not planned, or modifier 53 if repeat examination is planned).
Revised Codes
Guide Wire and Dilation
The EGD family includes a code for insertion of guide wire followed by dilation over guide wire. Insertion of guide wire code 43248 has been revised to describe passage of dilator(s) over a guide wire rather than dilation. Codes 43248 and 43249 (dilation codes) should not be reported with codes 43266 and 43270, as these codes (stent, ablation) include dilation.
Endoscopic Ultrasound (EUS)
Endoscopic ultrasound (EUS) examination codes 43237 and 43238 have been revised to describe EUS limited to the esophagus, stomach or duodenum and adjacent structures. Endoscopic ultrasound codes 43242 and 43259 have been revised to include examination of a surgically altered stomach where the jejunum is examined distal to the anastomosis. Clarification language has been included to address the extent of performance of the EUS examination as distinguished from the extent of the endoscopic visualization.
Pseudocyst Drainage
In addition to transmural drainage of pseudocyst as described in the current code 43240, EGD with transmural drainage of pseudocyst has been revised to specify that it includes endoscopic ultrasound, transmural drainage and placement of stent(s) to facilitate drainage, when performed.
Dilation Procedures
Dilation procedure codes have been added, revised and deleted to better describe current practice. EGD code 43249 has been revised to specify transendoscopic balloon dilation of less than 30 mm in diameter. Code 43233 (>30mm balloon, e.g., achalasia) includes fluoroscopic guidance, when used. Code 43245 has been revised to describe dilation of gastric/duodenal stricture(s) and the guide wire example has been removed from the examples in parentheses. Code 43233 includes moderate sedation, as indicated by the moderate sedation symbol.
Control of Bleeding
The parentheticals for code 43255, EGD with control of bleeding code 43255 have been revised. Code 43255 should not be reported for treatment of esophageal/gastric varices, which are reported with more specific codes 43243 (sclerotherapy) or 43244 (banding). Code 43236, submucosal injection, would also not be reported if
injection was part of the control of bleeding procedure.
GI Topics of Discussion
• Anatomy of the Upper Gastrointestinal Tract
• Esophagoscopy
• Esophageal Dilation
• Esophagogastroduodenoscopy
• EGD with procedures
• Anatomy of the Lower Gastrointestinal Tract
• Colonoscopy
• Colonoscopy with procedures
Upper Gastrointestinal Endoscopy
• Esophagogastroduodenoscopy
*Acronym = EGD
*Direct visual examination of the upper gastrointestinal tract by means of a flexible fiberoptic endoscope
*EGD describes a procedure in which the pyloric channel is traversed with the endoscope
*Code range 43235 – 43259
Gastroenterological procedures included in CPT code ranges 43753-43757 and 91010-91299 are frequently complementary to endoscopic procedures. Esophageal and gastric washings for cytology when performed are integral components of an esophagogastroduodenoscopy (e.g., CPT code 43235). Gastric or duodenal intubation with or without aspiration (e.g., CPT codes 43753, 43754, 43756) shall not be separately reported when performed as part of an upper gastrointestinal endoscopic procedure. Gastric or duodenal stimulation testing (e.g., CPT codes 43755, 43757) may be facilitated by gastrointestinal endoscopy (e.g., procurement of gastric or duodenal specimens).
When performed concurrent with an upper gastrointestinal endoscopy, CPT code 43755 or 43757 should be reported with modifier 52 indicating that a reduced level of service was performed.
GUIDELINES
This policy does not certify benefits or authorization of benefits, which is designated by each individual policyholder contract. Paramount applies coding edits to all medical claims through coding logic software to evaluate the accuracy and adherence to accepted national standards. This guideline is solely for explaining correct procedure reporting and does not imply coverage and reimbursement.
DESCRIPTION
Upper gastrointestinal (GI) endoscopy, or esophagogastroduodenoscopy (EGD) is usually performed to evaluate symptoms of persistent upper abdominal pain, nausea, vomiting, and difficulty swallowing or bleeding from the upper GI tract. EGD is more accurate than x-ray films for detecting inflammation, ulcers, or tumors of the
esophagus, stomach and duodenum and can detect early cancer, as well as distinguish between benign and malignant conditions when biopsies of suspicious areas are obtained.
Esophagogastroduodenoscopy (EGD) uses a flexible fiber-optic scope with a light and camera to examine the upper part of the GI system. The scope is inserted through the mouth into the upper GI tract allowing for direct visualization of the esophagus, stomach, and duodenum through the camera. This document does not address
upper gastrointestinal (GI) endoscopy in children, wireless capsule endoscopy, virtual endoscopy or in vivo analysis of gastrointestinal lesions via endoscopy.
POLICY
Upper gastrointestinal endoscopy does not require prior authorization. Appropriate ICD-10 diagnosis code (as listed below) required for coverage.
COVERAGE CRITERIA
HMO, PPO, Individual Marketplace, Elite/ProMedica Medicare Plan, Advantage
These procedures for adults aged 18 years or older can only be allowed if abnormal signs or symptoms or known disease are present.
- Indications which support EGD(s) for diagnostic purpose(s) are as follows:
*Upper abdominal distress which persists despite an appropriate trial of therapy;
*Upper abdominal distress associated with symptoms and/or signs suggesting serious organic disease (e.g., prolonged anorexia and weight loss);
*Dysphagia or odynophagia;
*Esophageal reflux symptoms which are persistent or recurrent despite appropriate therapy;
*Persistent vomiting of unknown cause;
*Other systemic diseases in which the presence of upper GI pathology might modify other planned management. Examples include patients with a history of GI bleeding who are scheduled for organ transplantation; long term anticoagulation; and chronic non-steroidal therapy for arthritis;
*X-ray findings of:
- A suspected neoplastic lesion, for confirmation and specific histologic diagnosis;
- Gastric or esophageal ulcer; or
- Evidence of upper gastrointestinal tract stricture or obstruction.
*The presence of gastrointestinal bleeding: - In most actively bleeding patients or those recently stopped;
- When surgical therapy is contemplated;
- When re-bleeding occurs after acute self-limited blood loss or after endoscopic therapy;
- When portal hypertension or aorto-enteric fistula is suspected; or
- For presumed chronic blood loss and for iron deficiency anemia when colonoscopy is negative.
*When sampling of duodenal or jejunal tissue or fluid is indicated;
*To assess acute injury after caustic agent ingestion; or
*Intraoperative EGD when necessary to clarify location or pathology of a lesion
- Indications which support EGD(s) for therapeutic purpose(s) are as follows:
*Treatment of bleeding from lesions such as ulcers, tumors, vascular malformations (e.g., electrocoagulation, heater probe, laser photocoagulation or injection therapy);
*Sclerotherapy for bleeding from esophageal or proximal gastric varices or banding of varices;
*Foreign body removal;
*Removal of selected polypoid lesions;
*Placement of feeding tubes (oral, percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy);
*Dilation of stenotic lesions (e.g., with transendoscopic balloon dilators or dilating systems employing guidewires); or
*Palliative therapy of stenosing neoplasms (e.g., laser, bipolar electrocoagulation, stent placement). - Sequential or periodic diagnostic upper GI endoscopy may be indicated for an appropriate number of procedures for active or symptomatic conditions.
*For follow-up of selected esophageal, gastric or stomal ulcers to demonstrate healing (frequency of followup EGDs is variable, but every two to four months until healing is demonstrated is reasonable);
*For follow-up in patients with prior adenomatous gastric polyps (approximate frequency of follow-up EGDs would be every one to four years depending on the clinical circumstances, with occasional patients with sessile polyps requiring every six-month surveillance initially);
*For follow-up for adequacy of prior sclerotherapy or banding of esophageal varices (approximate frequency of follow-up EGDs is very variable depending on the state of the patient but every six to twenty-four months is reasonable after the initial sclerotherapy/banding sessions are completed);
*For follow-up of Barrett’s esophagus (approximate frequency of follow-up EGDs is one to two years with biopsies, unless dysplasia or atypia is demonstrated, in which case a repeat biopsy in two to three months might be indicated); or
*For follow-up in patients with familial adenomatous polyposis (approximate frequency of follow-up EGDs would be every two to four years, but might be more frequent, such as every six to twelve months if gastric adenomas or adenomas of the duodenum were demonstrated). - The endoscopic retrograde cholangiopancreatography (ERCP) procedure is generally indicated for certain biliary and pancreatic conditions.
*ERCP is generally not indicated for the diagnosis of pancreatitis except for gallstone pancreatitis;
*ERCP is not usually indicated in early stages or in acute pancreatitis and could possibly exacerbate it;
*ERCP may be useful in traumatic pancreatitis to accurately localize the injury and provide endoscopic drainage;
*ERCP may be useful in pancreatic duct stricture evaluation;
*ERCP may be useful for the extraction of bile duct stones in severe gallstone induced pancreatitis;
*ERCP may be useful in detecting pancreatic ductal changes in chronic pancreatitis and also the presence of calcified stones in the ductal system. A pancreatogram may be performed and is likely to be abnormal in chronic alcoholic pancreatitis but less so in non-alcoholic induced types;
*ERCP may be useful in detecting gallstones in symptomatic patients whose oral cholecytogram and gallbladder ultrasonograms are normal; and
*ERCP may be indicated in patients with radiologic imaging suggestive of common bile duct stones or other potential pathology.
Limitations
- Indications for which EGD(s) are generally non-covered are as follows:
*Distress which is chronic, non-progressive, atypical for known organic disease, and is considered functional in origin (there are occasional exceptions in which an endoscopic examination may be done once to rule out organic disease, especially if symptoms are unresponsive to therapy);
*Uncomplicated heartburn responding to medical therapy;
*Metastatic adenocarcinoma of unknown primary site when the results will not alter management;
*X-ray findings of:
- asymptomatic or uncomplicated sliding hiatus hernia;
*uncomplicated duodenal bulb ulcer which has responded to therapy; or - Deformed duodenal bulb when symptoms are absent or respond adequately to ulcer therapy;
*Routine screening of the upper gastrointestinal tract;
*Patients without current gastrointestinal symptoms about to undergo elective surgery for non-upper gastrointestinal disease; or
*When lower GI endoscopy reveals the cause of symptoms, abnormal signs or laboratory tests (e.g., colonic neoplasm with iron deficiency anemia). Exceptions can be considered if medical necessity for this procedure can be demonstrated.
- Sequential or periodic diagnostic EGD is not indicated for:
*Surveillance for malignancy in patients with gastric atrophy, pernicious anemia, treated achalasia, or prior gastric operation;
*Surveillance of healed benign disease such as esophagitis, gastric or duodenal ulcer; or
*Surveillance during chronic repeated dilations of benign strictures unless there is a change in status
