Question: A new patient reports to the gastroenterologist with complaints of frequent belching and heartburn. After performing a level-two E/M service, the gastroenterologist performs a diagnostic EGD.
During the EGD, she also inserts a Bravo capsule and performs a reflux test. Tests came back negative for both cancer and gastroesophageal reflux disease (GERD). How should I code this scenario?
Answer: You should be able to report the EGD and the Bravo insertion separately along with an E/M service. On the claim, report the following:
• 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic,with or without collection of specimen[s] by brushing or washing [separate procedure]) for the EGD
• 91035 (Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode placement, recording, analysis and interpretation) for the Bravo cap insertion
• 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expandedproblem focused history; an expanded problem focused examination; straightforward medical decision making …) for the E/M
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99202 to show that the E/M was separate from the other procedures
• 787.1 (Heartburn) and 787.3 (Flatulence, eructation, and gas pain) appended to 43235, 91035, and 99202 to represent the patient’s symptoms.
Crucial: The date of service for 91035 should be the date the gastroenterologist retrieves the recorder and interprets the capsule data.
Unravel the mysteries of MPFSDB – what it is and what crucial reference information is listed in it? With gasteroenterology coding expert Jill Young.
Related articles:
- Cardiology Coding Education: Pacemaker Lead Check Question: The cardiologist documented testing pacemaker leads using fluoroscopy…
- Coder’s Anatomy Double-Take: What is NERD? Question: In the doctor’s notes, it states the patient has…
- 3 Mythbusters Overcome Your Urogynecology Bladder Scan Coding Troubles Uncover how you can bill a distinct E/M visit…