Sherry Posted Fri 19th of January, 2018 11:24:44 AM
Hello, looking for some advice on this procedure physician had to perform; prior to this EGD, that morning they performed an EGD, there was a large clot that was bleeding that they did a bleeding control on, we billed that as 43255//physician stated he wanted to give the patient a couple of hours and perform a repeat EGD to check on that bleed, so that afternoon patient went back in to have the other EGD, below is what was done during that EGD. Reading this report, i'm wanting to confirm if i'd bill it as followed: 43247-76 and 43239-76-59; Modifier 76 to represent them coming back in. I'm conflicted on the removal by snare portion- and I billing it right with the 43247-76 for removal of that clot? Any assistance on this is greatly appreciate, here is the procedure documentation:
The examined esophagus was normal.
One non-bleeding cratered gastric ulcer with adherent clot was found on
the lesser curvature of the stomach. The lesion was 40 mm in largest
dimension. Clot removal with snare was attempted. This was successful
and revealed a non-bleeding lesion with pigmented material. Area was
successfully injected with 4 mL of a 1:10,000 solution of epinephrine
for hemostasis. Biopsies were taken of the ulcer margin with a cold
forceps for histology. Given no active bleeding or vissible vessel
thermal therapy was not used.
Hematin (altered blood/coffee-ground-like material) was found in the
Diffuse mild inflammation characterized by erythema was found in the
gastric antrum. Biopsies were taken with a cold forceps for Helicobacter
SuperCoder Answered Mon 22nd of January, 2018 08:22:06 AM
Please look into the code 43251 as it includes snare and removal of lesions instead of CPT code 43247 and 43239.