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Answers to Compliance and Medical Coding Questions.
  1. Sherry Posted 2 month(s) agoRelated Topics

    The physician performed an EUS, he performed an FNA on 5 abnormal lymph nodes, but he also did what seems like drainage but also biopsy on a pleural effusion. Here is how he words it: "A moderate-sized pleural effusion was present. This fluid was visualized endosonographically as an anechoic structure. It was triangular. The pleural effusion contained no thick septations. There was floating debris present within the pleural effusion. Diagnostic and therapeutic needle aspiration for fluid was performed. Color Doppler imaging was utilized prior to needle puncture to confirm a lack of significant vascular structures within the needle path. One pass was made with the 19 gauge needle using a transesophageal approach. A stylet was used. The amount of fluid collected was 20 mL. The fluid was turbid, yellow and watery. Sample(s) were sent for cytology." Should we only bill the FNA or should we bill the FNA and an unspecified code for the fluid that was aspirated. I know for the most part it probably should just be FNA since it was collected and sent for cytology, I just want to confirm because of how it was all worded, just to be 100% I don't miss anything.

  2. SuperCoder Posted 2 month(s) ago

    Hi Sherry,

    For endoscopy procedures that include EUS with biopsy or FNA specimen extraction, one can choose one of the following three codes :

    • 43232 -- Esophagoscopy, rigid or flexible; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s)
    • 43238 -- Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transendoscopic ultrasound- guided intramural or transmural fine needle aspiration/biopsy(s), esophagus (includes endoscopic ultrasound examination limited to the esophagus)
    • 43242 -- ... with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum and/or jejunum as appropriate).

    Hope this helps!

About this Question

  • Posted by 30421 Sherry, 2 month(s) ago. There are 2 posts. The latest reply is from SuperCoder.