Selina Posted Thu 09th of January, 2020 22:28:48 PM
Hello, First case: Patient was scheduled for a lower EUS but due to anatomy, they were unable to reach area to do EUS so he billed it as a flex sig w/bx 45331 and 45335 submucosal injection. Would this be correct or should 45341 with incomplete modifier 53 also be included? Second case: EUS w/FNA (43238), but the doctor specified that no EGD was done. Is there a code for just an EUS with no EGD or is 43238 appropriate?
SuperCoder Answered Fri 10th of January, 2020 06:40:20 AM
Thanks for your question.
Based on the limited documentation, we can suggest you the following:
In first case, if ultrasound was not performed, then you should not report codes 45331 and/or 45335 because documentation has not mentioned anything about biopsy or submucosal injection. Instead, you may report code 45330 (Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)) since ultrasound was not performed.
In second case, when EGD was not done, code 43238 (Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), (includes endoscopic ul ) cannot be reported. If it was a gastrointestinal endoscopic ultrasound, then you may report code 76975 (Gastrointestinal endoscopic ultrasound, supervision and interpretation)
Please check your documentation carefully. Please feel free to write if you have any question.