Resource Gastro Coding

2023 Coding & Payment Quick Reference Select Gastroenterology (GI) Stenting Procedures

Coding options listed within this guide are commonly used codes and are not intended to be an all-inclusive list.
We recommend consulting your relevant manuals for appropriate coding options.

https://www.bostonscientific.com/content/dam/bostonscientific/Reimbursement/Gastroenterology/pdf/Stenting_Coding_and_Payment_Quick_Reference.pdf?fbclid=IwAR0io4TwNu1MKqIo3v4watd1CyfrBLX9kIAbTzn8wx8Y1lHqro114O6qlTo

 

[JamiaW_80513]

2023 Coding & Payment Quick Reference Select Gastroenterology (GI) Stenting Procedures

Coding options listed within this guide are commonly used codes and are not intended to be an all-inclusive list.
We recommend consulting your relevant manuals for appropriate coding options.

https://www.bostonscientific.com/content/dam/bostonscientific/Reimbursement/Gastroenterology/pdf/Stenting_Coding_and_Payment_Quick_Reference.pdf?fbclid=IwAR0io4TwNu1MKqIo3v4watd1CyfrBLX9kIAbTzn8wx8Y1lHqro114O6qlTo

Thank you for this!!!

 

[Lori]

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

For the purposes of endoscopy, the upper GI tract includes the esophagus, stomach and duodenum (esophagogastroduodenoscopy [EGD] or upper GI endoscopy UGIE), and the lower GI tract includes the anus, rectum, colon, and cecum (anoproctosigmoidocolonoscopy or lower GI endoscopy)

The GI Tract (Gastrointestinal Tract) starts from the mouth, inside the mouth, there are many accessory organs that assist in the digestion of food are:

1. The tongue,
2. The teeth,
3. Salivary glands (Parotid, Sub-lingual and Sub-mandibular glands)

The pharynx is a funnel-shaped tube connected to the posterior end of the mouth. It moves the chewed food from the mouth to the esophagus.

The pharynx also plays a role in the respiratory system, as air from the nasal cavity, passes through the pharynx on it's way to the larynx and to the lungs. The pharynx contains a flap of tissue known as the epiglottis that acts as a switch to route food to the esophagus and air to the larynx.

The esophagus is a muscular tube connecting the pharynx to the stomach. cardiac sphincter is present in the junction between esophagus and stomach.

The stomach is a muscular sac that is located on the left side of the abdominal cavity, just inferior to the diaphragm. It acts as a storage place for food so that it digests large meals properly.

The small intestine is divided into:

1. Duodenum
2. Jejunum
3. Ileum

Accessory digestive organs found in the abdominal region are:

1. Liver
2. Gallbladder
3. Pancreas

The liver is an accessory organ of the digestive system located to the right upper quadrant of the abdomen, the right side of the stomach, just inferior to the diaphragm and superior to the small intestine.

The liver is the largest internal organ in the body. The liver has many different functions in the body, but the main function of the liver in digestion is the production of bile and its secretion into the small intestine (duodenum).


The gallbladder is a small, pear-shaped organ located just inferior to the liver. The gallbladder is used to store and recycle excess bile from the small intestine so that it can be reused for the digestion of subsequent meals.


The pancreas is a large gland located just inferior and posterior to the stomach. The pancreas secretes digestive enzymes into the small intestine to complete the chemical digestion of foods. The endocrine function of the pancreas is Insulin production.

From Small intestine, the digested food passes to the large intestine. via Ileocecal valve.


The large intestine is a long, thick tube divided into:

1. Cecum,
2. Ascending colon,
3. Transverse colon,
4. Descending colon,
5. Sigmoid colon
6. Rectum
7. Anus





The large intestine is located just inferior to the stomach and wraps around the superior and lateral border of the small intestine. The large intestine absorbs water and contains many symbiotic bacteria that aid in the breaking down of wastes to extract some small amounts of nutrients. Faeces in the large intestine exit the body through the anal canal.


Functions of the digestive system:
Ingestion
Secretion
Mixing and movement
Digestion
Absorption
Excretion

Common disease of Digestive system:


1. GERD – Stomach acid flows backwards causing discomfort
2. Crohn’s disease - Inflammation that affects the lining of the digestive tract.
3. Irritable bowel syndrome- Is a problem that affects the large intestine.
4. Diverticulosis - Small, bulging pouches develop in the digestive tract.
5. Colitis - Inflammation of the inner lining of the colon.
6. Colon Polyp - A small clump of cells that forms on the lining of the colon.

Common Signs and Symptoms of Digestive system

1. Abdominal pain
2. Blood in the stool
3. Bloating
4. Constipation
5. Diarrhea
6. Heartburn
7. Incontinence
8. Nausea and vomiting



MEDICAL TERMS:

1. Mouth - Oral / Stomato
2. Lip - Labio / Cheilo
3. Tooth - Dento / Odonto
4. Tongue - Glosso / Linguo
5. Uvula - Uvulo
6. Salivary gland - Sialo
7. Gums - Gingivo
8. Pharynx - Pharyngo
9. Esophagus - Esophago
10. Stomach - Gastro
11. Duodenum - Duodeno
12. Jejunum - Jejuno
13. Ilium - Ilio
14. Liver - Hepato
15. Gallbladder - Cholecysto
16. Common bile duct - Choledocho
17. Bile - Chol
18. Small Intestine - Entero
19. Colon - Colo
20. Cecum - Ceco
21. Sigmoid colon - Sigmoido
22. Rectum - Procto / Recto
23. Anus - Ano



MEDICAL ABBREVIATIONS:

1. CT - Computed tomography
2. ERCP - Endoscopic retrograde cholangiopancreatography
3. GERD - Gastroesophageal reflux disease
4. GI – Gastrointestinal
5. HCL - Hydrochloric acid
6. IBS - Irritable bowel syndrome
7. IBD - Inflammatory bowel disease
8. LFT - Liver function test
9. LLQ - Left lower quadrant
10. LUQ - Left upper quadrant
11. MRA - Magnetic resonance angiography
12. MRI - Magnetic resonance imaging
13. RLQ - Right lower quadrant
14. RUQ - Right upper quadrant

ENDOSCOPY PROCEDURES:

Esophagoscopy (43191 – 43232)
Visualization of the esophagus via a thin tube-like instrument (Rigid type or Flexible type).
Examination of cricopharyngeus muscle to the Gastroesophageal junction it may also include a proximal region of the stomach.
The instrument is inserted via oral (Transoral) or via the nose (Transnasal).

Esophagogastroduodenoscopy (43235 – 43210)
Visualization of the esophagus, stomach and duodenum. A flexible instrument inserted via Transoral.
If the duodenum is deliberately not examined then append modifier 52 /53 based on repeat exam is planned or not.
A. No repeat exam is planned – append modifier 52
B. Repeat exam is planned – append modifier 53

Esophagus to Jejunum (44360 – 44373)
Small Intestine (Enteroscopy) Endoscopy –
1. Antegrade Transoral –
A. Esophagus to Jejunum (44360 – 44373)
B. Esophagus to ileum (44376 – 44379)

2. Retrograde via Anal/colon stoma – 44799 (Unlisted)

Note: If an endoscope can’t be advanced at least 50 cm beyond the pylorus – Code as Esophagogastroduodenoscopy
Esophagus to ileum (44376 – 44379)

Ileoscopy through a stoma (44380 - 44384)
Colonoscopy through a stoma (44388 - 44408)
Examination of the intestine via the stoma.

Proctosigmoidoscopy (45300 – 45327)
Examination of the rectum and may include the examination of a portion of the sigmoid colon

Sigmoidoscopy (45330 – 45347)
Examination of the rectum and sigmoid colon and may include the examination of a portion of the descending colon.

Colonoscopy (45378 – 45398
Examination of the entire colon (Rectum to Cecum) may include the examination of the terminal ileum.
1. Modifier 53: If a patient is scheduled for diagnostic / screening colonoscopy but the physician is unable to advance the scope to the Cecum.
2. Modifier 52: If a patient is scheduled for a therapeutic colonoscopy but the physician is unable to advance the scope to the Cecum.

Anoscopy (46600 – 46615)
Examination of the Anus

​

 

[Lori]

ENDOSCOPY PROCEDURES - General Coding Guidelines:

1. Procedures like venous access, infusion and injection, non-invasive oximetry, anesthesia provided during endoscopy procedures are considered as part of the procedure.

2. If the same therapeutic endoscopy procedure is performed repeatedly in the same area, Bill the service once. If different therapeutic procedures are performed multiples endoscopy codes can be used accordingly.

3. Diagnostic endoscopy is always included in the therapeutic endoscopy.

4. When the small intestine endoscopy CPT ranges from 44360 - 44386 is performed as part of another major procedure then endoscopy is considered as part of the procedure, hence should not be billed separately along with more extensive procedures like enterostomy etc.

5. When diagnostic endoscopy of the hepatic/ biliary/pancreatic system using separate approach is performed – append modifier 51.

6. When a biopsy is performed and followed by excision/ destruction/removal of the biopsied lesion, then the biopsy is considered as part of the procedure should not be billed separately.

7. Bleeding occurs as a result of endoscopic procedure and control of bleeding in the same session of other major endoscopy procedure is considered as part of the procedure. If the bleeding control is performed in separate sessions following endoscopy procedure append modifier 78 (Postoperative return to the operating room following the related procedure)

8. When sigmoidoscopy is performed along with colonoscopy in the same session, code only the colonoscopy.

9. When a sigmoidoscopy and colonoscopy is performed as part of another major procedure then these services are considered as part of the procedure should not be billed separately. Eg: colectomy procedure.

10. If the larynx is viewed using esophagoscope, don’t bill laryngoscope separately.
ERCP – Endoscopic retrograde cholangiopancreatography

ERCP is a procedure that combines upper gastrointestinal (GI) endoscopy and x-rays to diagnose and/or treat problems of the bile and pancreatic ducts.

1. An ERCP is considered complete if one or more of the ductal system (biliary/pancreas) is visualized.
2. If ERCP is attempted but with unsuccessful cannulation of any ductal system, - report Esophagogastroduodenoscopy procedure codes.
3. For reporting purpose
Pancreas: Major and minor ducts
Biliary tree: Common bile duct, right hepatic duct, left hepatic duct, cystic duct.
4. ERCP with stent placement includes balloon dilation in that duct.
5. ERCP with more than one stent placement (Different duct or side by side in the same duct) - report CPT 43274 more than once with modifier 59.
6. ERCP with multiple stent exchange – report 43276 more than once with mod 59.
7. ERCP with balloon dilation of multiple ducts reported with modifier 59
8. Sphincteroplasty or dilation of the ductal stricture is required before proceeding to remove the stone from the duct during the same session may be reported separately. Note: Dilation that is incidental to the passage of an instrument to clear stone is included.
9. Stone destruction includes stone removal in the same ductal system.

Allotransplantation Procedures:
Any organ transplantation, there are three distinct components,

A. Donor – Cadaver or Living

- Harvesting organ and cold preservation.
B. Backbench work

- Standard preparation prior to transplant.
C. Recipient allotransplantation with or without recipient organ removal.

- Transplantation of allograft and care of the recipient.
Percutaneous Biliary Procedures:
- Transhepatic
- Transcholecystic

Drainage catheter:
A. External biliary drainage
B. Internal and External biliary drainage
C. Internal biliary drainage (Stent)

External – Catheter placed into a bile duct to drain only externally.

Internal and External – Two-way catheter (Catheter terminates in the small intestine to drain internally as well as externally).

Internal Stent: Percutaneously placed device drains internally.

Stent codes (47538, 47539, 47540) – reported only once if,

- One or more overlapping or serial stents placed within a single duct
- Bridging more than one ductal segment via single access.

Stent codes (47538, 47539, 47540) – Coded more than once with Mod 59

- Side by side (Double barrel) within a single duct.
- Two or more stents into the separate bile duct.
- Two or more separate access.

Diagnostic Cholangiography (47531 and 47532) is included with percutaneous biliary procedures.
Balloon dilation (47542) is included in stent placement codes.
Incidental removal of debris is included in catheter /stent placement codes.
Balloon dilation (47542) is included in the removal of calculi or debris (47544).
Biliary endoscopy, percutaneous via T-tube (47552- 47556)

Hernioplasty, Herniorrhaphy, Herniotomy:
Hernia repair codes are based on:

- Type of a hernia (Inguinal, femoral, Incisional etc)
- Initial or recurrent.
- Reducible or incarcerated/strangulated.

Post-conception age: Age at birth plus age at the time of operation.

- (Preterm – 25 weeks at birth plus age 15 weeks at the time of operation = 40 weeks)

The excision/repair of strangulated organs such as testicle, intestine, ovaries are reported by using the appropriate code in addition with hernia repair codes.

Don’t code CPT 49568 (mesh or other prostheses) along with hernia repair codes except for Incisional hernia repair codes (49560-49566)

Codes 49491 – 49451 are unilateral procedures – append modifier 50 for bilateral procedures.

For reduction and repair of an intra-abdominal hernia – CPT 44050

Omphalocele: Birth defect intestine or abdominal organs are outside of the body because of a hole in the belly button.

A. Small – small portion of the intestine outside the body
B. Large – Involving organs like liver, spleen and intestine.

Gastrostomy / Duodenostomy / Jejunostomy / Colonic tube

Nasogastric tube (or) Orogastric tube is included.

The codes are based on,
A. Initial placement (49440 - 49442)
B. Conversion (49446)
C. Replacement (49450 - 49452)
D. Removal of obstructive material (49460)
E. Checking the tube (49465)

Note: If an existing tube is removed and a new tube is placed via separate access – Not considered as a replacement, code as Initial placement codes.

Endoscopic placement of percutaneous Gastrostomy tube – CPT 43246

Change of Gastrostomy tube, percutaneous, without imaging or endoscopic guidance – CPT 43760

Placement of Enterostomy / Cecostomy tube, open – CPT 44300

Laparoscopy Procedures:

- Minimally invasive surgery, a fibre-optic instrument is inserted through a small incision made in the abdomen wall to examine or operate on the interior of the abdominal or pelvic cavities.

Surgical laparoscopy always includes Diagnostic laparoscopy.

Bariatric Surgery:

- Weight loss is achieved by reducing the size of the stomach with a gastric band or through the removal of a portion of the stomach (sleeve Gastrectomy or biliopancreatic diversion with duodenal switch) or by resecting and re-routing the small intestines to a small stomach pouch (gastric bypass surgery).


Hemorrhoids / Piles:
- Swollen and inflamed veins in the rectum and anus that cause discomfort and bleeding.
A. Internal hemorrhoids
B. External hemorrhoids

Don’t report Anoscopy (46600) along with hemorrhoids procedures.

​

 

[Lori]

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.

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.