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Gastroenterology Coding Alert

Documentation Key to Optimize Billing for Endoscopic Ultrasound

Endoscopic ultrasound is one of several gastrointestinal procedures for which there may not be a specific CPT code, depending on the part of the intestinal tract where the procedure is being performed. Gastroenterologists may have to choose between using an unlisted code and modifier -22 (unusual procedural services) to report the procedure.

In endoscopic ultrasound, an ultrasound device is attached to the end of the endoscope in addition to the standard endoscopic camera. Once the endoscope is passed into the gastrointestinal tract, ultrasound images will appear instantaneously on a monitor situated near the gastroenterologist, which allows him or her to obtain structural information about the gastrointestinal tract. Ultrasound, also referred to as echography, sonography and ultrasonography, also can be used by a gastroenterologist to guide the insertion of a biopsy needle into a tumor or lesion.

Use 43259 for Upper GI Procedures

Endoscopic ultrasound is made up of two components: the endoscopic procedure used to insert the ultrasound device into the body and the use of the ultrasound itself. When the gastroenterologist performs an endoscopic ultrasound in the upper gastrointestinal tract, then code 43259 (upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with endoscopic ultrasound examination) should be used to report the procedure, according to Michael Weinstein, MD, gastroenterologist in Washington, D.C., and a representative to the American Medical Association (AMA) CPT advisory panel. The endoscopy, however, must include the examination of the esophagus, stomach, and either the duodenum or jejunum as appropriate, stresses section 15100.A of the Medicare Carriers Manual.

Coding Lower GI Procedures

Although endoscopic ultrasound also is performed on other areas of the gastrointestinal tract, such as the colon and rectum, there are currently no specific CPT codes to cover those procedures. Gastroenterologists may report the base endoscopic procedure, says Weinstein, with modifier -22 attached. If a rectal ultrasound is performed during a colonoscopy, then code 45378 (colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]) could be reported with modifier -22 attached to it.

When attaching modifier -22 to a procedure code, Medicare and most commercial insurance companies require two separate pieces of documentation be submitted along with the claim. The first is a copy of the operative note for the procedure, which documents the unusual difficulty of the case. The amount of time the procedure took should be noted in the report.

There also should be a letter from the gastroenterologist explaining how the service differs from the [...]