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CPT CODE

Heidi Posted Mon 08th of February, 2016 12:55:29 PM

Need assistance in figuring out what 2016 CPT code I need to use:

I have a procedure report from an Endoscopic Upper GI Endoscopy- the doctor is stating the following: "The Endoscope was introduced through the Gastrostomy, and advanced to the Cricopharyngeal esophagus." The upper GI endoscopy was accomplished without difficulty.

Procedural Findings:
A benign-appearing, intrinsic severe (stenosis; an endoscope cannot pass) stenosis measuring 1 cm (in length) was found in the upper third of the esophagus and was non-traversed. Placement of a short 0.025 inch Jagwire was attempted. This passed successfully. A TTS dilator was passed through the scope. Dilation with an 8-9-10 mm balloon (to a maximum balloon size of 8 mm) dilator was performed under fluoroscopic guidance. A guidewire was placed under fluoroscopic guidance and the scope was withdrawn. Dilation was performed with a Savary dilator with moderate resistance at 10 mm. A guide wire was inserted into the stomach and the endoscope was removed. A 18 Fr nasogastric tube was advanced over the guide wire into the stomach body. There was evidence of an intact gastrostomy with an occluded G-tube present in the gastric body. The scope was withdrawn. Dilation was performed with a Hegar dilator with no resistance at 10 mm. The examined duodenum was normal.

SuperCoder Answered Tue 09th of February, 2016 07:44:49 AM

“AAE does not provide coding for operative reports and chart notes.
SuperCoder offers SuperCoding on Demand (SOD) (http://www.supercoder.com/coding-answers/coding-on-demand) for coding of an operative report or chart note and you can contact (866)228-9252 or e-mail customerservice@supercoder.com for more information. ’

Heidi Posted Tue 09th of February, 2016 08:27:22 AM

Well what I'm looking for is what code would I use when an Endoscope goes through the Gastrostomy versus the esophagus; they are doing an "EGD," but instead of going through the esophagus to the duodenum; they are going through the Gastrostomy (in the stomach).

Can I please get assistance with what CPT code I should for that?

SuperCoder Answered Wed 10th of February, 2016 01:33:07 AM

Appropriate CPT code would be 43999(Unlisted procedure, stomach)

Heidi Posted Wed 10th of February, 2016 08:12:52 AM

Thank you for your assistance!

SuperCoder Answered Wed 10th of February, 2016 23:55:09 PM

Happy to Help!

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