CPT code 43235, 43236, 43237, 43238, 43239 – EGD codes

Indications and Limitations of Coverage and/or Medical Necessity


The following conditions are generally accepted as indications for the performance of EGD(s).




Indications that support EGD(s) for diagnostic purpose(s) are:




Upper abdominal distress that persists despite an appropriate trial of therapy. 


Upper abdominal distress associated with symptoms and/or signs suggesting 
serious organic disease (e.g., anorexia and weight loss). 


Dysphagia or odynophagia. 


Esophageal reflux symptoms that are persistent or recurrent despite appropriate therapy. 


Persistent vomiting of unknown cause. 


Other system disease in which the presence of upper GI pathology might modify other planned management. Examples include patients with a history of GI bleeding who are scheduled for organ transplantation, long-term anticoagulation, and chronic non-steroidal therapy for arthritis. Please note that this Indication does not provide coverage for routine pre-operative EGD for patients in whom bariatric surgical procedures are contemplated or planned




X-ray findings of: 


A suspected neoplastic lesion for confirmation and specific histologic diagnosis. 


Gastric or esophageal ulcer. 
Or, 
Evidence of upper gastrointestinal tract stricture or obstruction. 




Gastrointestinal bleeding: 


In most actively bleeding patients. 
When surgical therapy is contemplated. 
When rebleeding occurs after acute self-limited blood loss. 
When portal hypertension or aorto-enteric fistula is suspected. 
Or, 
For presumed chronic blood loss and for iron deficiency anemia when colonoscopy is negative. 




When sampling of duodenal or jejunal tissue or fluid is indicated. 
To assess acute injury after caustic agent ingestion. 
Or, 
Intraoperative EGD when necessary to clarify location or pathology of a lesion. 








 

Indications that support EGD(s) for therapeutic purpose(s) are:


Treatment of bleeding from lesions such as ulcers, tumors, vascular malformations (e.g., electrocoagulation, heater probe, laser photocoagulation or injection therapy). 
Sclerotherapy and/or band ligation for bleeding from esophageal or proximal gastric varices. 
Foreign body removal. 
Removal of selected polypoid lesions. 
Placement of feeding tubes (per oral, percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy). 
Dilation of stenotic lesions (e.g., with transendoscopic balloon dilators or dilating systems employing guide wires). 
Or, 
Palliative therapy of stenosing neoplasms (e.g., laser, bipolar electrocoagulation, stent placement). 






Sequential or periodic diagnostic EGD may be indicated:


For follow up of selected esophageal, gastric or stomal ulcers to demonstrate healing (frequency of follow-up EGD is variable, but every two to four months until healing is demonstrated is reasonable). 


For follow up in patients with prior adenomatous gastric polyps (approximate frequency of follow-up EGDs would be every one to four years depending on the clinical circumstances, with occasional patients with sessile polyps requiring every six months surveillance initially), and similarly with surveillance of confirmed high-grade gastric dysplasia. 


For follow up for adequacy of prior sclerotherapy and/or band ligation of esophageal varices (approximate frequency of follow-up EGDs is variable depending on the state of the patient but every six to 24 months is reasonable after the initial sclerotherapy sessions are completed). 


For follow-up of Barrett’s esophagus (approximate frequency of follow-up EGDs is one to two years with biopsies, unless dysplasia is demonstrated, in which case, a repeat biopsy in two to three months might be indicated). 


Or, 
For follow-up in patients with familial adenomatous polyposis (approximate frequency of follow-up EGDs would be every two to four years, but might be more frequent, such as every six to 12 months, if gastric adenomas or adenomas of the duodenum were demonstrated).


For follow-up of patients with severe, refractory gastroesophageal reflux disease where the concern of malignant degeneration exists (approximate frequency of every ten years)



Billing and Coding Tips


Beginning with dates of service on or after April 1, 2015, ClaimsXten removed their incidental edit on Current Procedural Terminology (CPT®) code 43235  esophagogastroduodenoscopy (EGD), flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)) when reported with CPT codes 43770-43775 (laparoscopy, surgical, gastric restrictive procedures). However, when an EGD is performed following a gastric restrictive  procedure to confirm there is no leakage, we consider the EGD to be an integral part of the primary procedure and not eligible for separate reimbursement. Therefore, beginning with claims processed on or after August 17, 2015, we will again apply the bundled services incidental edit on CPT code 43235 (EGD) when reported with CPT codes 43770-43775 (gastric restrictive procedures). This information will be documented in Section 2 of our policy. 


Unbundling occurs when multiple procedure codes are submitted for a group of procedures that are described by a single comprehensive code. An example of Unbundling would be fragmenting one service into component parts and coding each component as if it were a separate service. For example, the correct CPT comprehensive code to use for upper gastrointestinal endoscopy with biopsy of stomach is CPT code 43239. Separating the service into two component parts,
using CPT code 43235 for upper gastrointestinal endoscopy and CPT code 43600 for biopsy of stomach is inappropriate


CPT Codes: 45378, 43239, 43235, 45385, 45380 Reminder: In accordance with Oxford’s policies and procedures, an office facility fee (code OFAC2) will be paid for these five codes if the provider chooses to perform them in his or her office




If an EGD is performed with a biopsy, and then the physician removes the scope and performs an Esophageal Dilation by unguided sound, it should be billed using two CPT codes – CPT code 43239 for the EGD with a biopsy and code 43450 for the Esophageal Dilation.


If an EGD is performed with a biopsy, and then the physician performs an Esophageal Dilation using the scope instrument itself, only the 43239 EGD with Biopsy code is billable. If no Biopsy is performed and the only procedure performed is an Esophageal Dilation using the scope instrument itself, only the 43235 Diagnostic EGD code is billable.


Use code 43243 for an EGD with injection sclerosis of esophageal and/or gastric varices. Use code 45381 for a Colonscopy in which Saline is injected to raise a polyp, ink is injected or Tattooing of a lesion is performed. This code is not usually Unbundled from the Biopsy or Polypectomy codes.


If the physician attempts – but fails – to remove a polyp by one (example, Snare) technique, but is successful at removing the polyp via another technique (such as Hot Biopsy Forceps) only bill the CPT code for the procedure that was successful (45384).


If an EGD with a Polypectomy by Cold Biopsy Forceps is performed, use the 43258 Ablationcode – not the 43239 Biopsy code.


Use code 45380 for Colonoscopy procedures performed with Biopsies and/or the Removal of all or portions of Polyps using Cold Biopsy Forceps.


Use code 45383 for colon polyps treated by the Ablation technique, where a polyp is removed using the APC, laser, heat probe, or other device to cauterize it or the remnants of a polyp previously removed during a colonoscopy procedure. Use this code also when polyps are Fulgurated.



Colonoscopy procedures performed through Stomas (Ileostomy and Colostomy patients) are coded from section 44388-44397 codes. 




New Codes


Balloon Dilation of Esophagus


EGD code 43233 (out of sequence) has been established to report balloon dilation of 30 mm in diameter or larger. This dilation procedure includes fluoroscopic guidance, when used. 




Endoscopic Mucosal Resection


Code 43254 has been established to report endoscopic mucosal resection (EMR) with EGD. Code 43254 includes removal of tumor(s), polyp(s) or other lesion(s) by snare technique (43251); directed submucosal injection(s) (43236); and band ligation (43254), so these services are not separately reportable when performed on the same lesion during the same session. Biopsy (43239) performed on the same lesion as EMR is not separately reportable. Code 43254 includes moderate sedation, as indicated by the moderate sedation symbol.


Ultrasound-Guided Injections / Placement of Fiducial Markers


Code 43253 has been established to describe ultrasound-guided transmural injection of substances (e.g., celiac axis injection) or fiducial markers. This code includes endoscopic ultrasound (EUS) of the esophagus, stomach, and either the duodenum or a surgically-altered stomach where the jejunum is examined distal to the anastomosis.  




43239 Esophagogastroduodenoscopy, flexible, transoral; biopsy, single or multiple Parent code revised 





43254 Esophagogastroduodenoscopy, flexible, transoral; EMR (endoscopic mucosal resection) New Code for 2014 Do not report biopsy 43239, submucosal injection 43236, band ligation 43244 or snare removal 43251 separately for same lesion

Key Documentation Terms


Within this area of procedures it is important to make sure that the  documentation clearly identifies what was examined and the procedure(s) performed. Codes with in this section are further classified by the procedures performed (e.g., biopsy, injection, removal of foreign body, and removal of tumor).


When reporting procedures within this family of codes, each procedure must be clearly documented. For instance when performing code 43250 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery, at the minimum the documentation should include what was removed and the key terms “hot biopsy forceps” or “bipolar cautery.” Code 43251 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique, should include what was removed and the key terms “removal of” and “snare technique” in the documentation for the procedure. 


Bundling CPT 43239


Unbundling Unbundling occurs when multiple procedure codes are submitted for a group of procedures that are described by a single comprehensive code. An example of Unbundling would be fragmenting one service into component parts and coding each component as if it were a separate service. For example, the correct CPT comprehensive code to use for upper gastrointestinal endoscopy with biopsy of stomach is CPT code 43239. Separating the service into two component parts, using CPT code 43235 for upper gastrointestinal endoscopy and CPT code 43600 for biopsy of stomach is inappropriate


Unbundling



 Unbundling occurs when multiple procedure codes are submitted for a group of procedures that are described by a single comprehensive code. An example of Unbundling would be fragmenting one service into component parts and coding each component as if it were a separate service. For example, the correct CPT comprehensive code to use for upper gastrointestinal endoscopy with biopsy of stomach is CPT code 43239.  Separating the service into two component parts, using CPT code 43235 for upper gastrointestinal endoscopy and CPT code 43600 for biopsy of stomach is inappropriate (per CMS National Correct Coding Policy Manual).




Esophagogastroduodenoscopy (EGD) CPT CODES


Revised Codes


• 43235 Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) b brushing or washing, when performed (separate procedure) $670.47


• 43236; with directed submucosal injection(s) any substance $670.47


• 43237; with endoscopic ultrasound examination limited to the esophagus stomach or duodenum, and adjacent structures $1,013.05


• 43238; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), esophagus (includes endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures) $1,013.05


• 43239; with biopsy, single or multiple $670.47