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Gastroenterology Coding Alert

Reader Questions:

43248 and 43239: Don't Overlook Your Upper GI Encoscopy Codes

Question: How should I report an endoscopic procedure based on the following op note? "The patient was placed in the left lateral decubitus position. After adequately sedating the patient, the physician performed esophageal intubation under direct visualization using diagnostic front-view endoscope. The physician advanced the scope all the way to the descending duodenum, and found a benign appearing, most likely reflux induced GE junction stricture with maximum diameter of approximately 12 mm. The stricture corresponds with Z line located at 37 cm from incisors. There was also a 3-cm hiatal hernia. Biopsies from the GE junction stricture were taken for histologic evaluation in bottle #2. Biopsies from normal appearing mucosa and stomach antrum and body were taken to check for H. pylori in bottle #1. A guidewire was introduced into the stomach antrum and the scope was withdrawn. The esophageal stricture was then dilated with American dilators #48 and 51 French [...]

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