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Billing and Coding Endoscopic Ultrasound in 2018

by | Aug 16, 2018 | Medical Billing, Resources | 0 comments

Introduced in 1980, endoscopic ultrasound or endoscopic ultrasonography (EUS) is a minimally invasive endoscopic technique. With its expanding diagnostic and therapeutic uses, this unique interventional modality is built into everyday practice in the field of gastroenterology. Payer policies vary and need to be verified prior to treatment for limitations on diagnosis, coding or site of service requirements. Partnering with an experienced gastroenterology medical billing company is a practical option to submit accurate and appropriate claims for the use of EUS.

EUS was initially used to get detailed images of remote organs, such as the pancreas and abdominal lymph nodes. With the advent of fine needle aspiration, the indications for EUS expanded to include tissue sampling for diagnostic purposes. Endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-FNA) is used for obtaining a definite tissue diagnosis from lesions outlined by endosonography. Though not easy to master, EUS-FNA is now a routine therapeutic procedure.

EUS supplements the information obtained with CT or MRI imaging. It is a minimally invasive alternative to various surgical interventions. For instance, using EUS to take needle biopsies from abnormal areas of the pancreas avoids the need for exploratory surgery. This ultrasound technique is used evaluate the following:

  • esophageal and stomach linings
  • upper gastrointestinal tract comprising the esophagus, stomach and duodenum
  • lower gastrointestinal tract including the colon and rectum
  • other organs near the gastrointestinal tract, including the lungs, liver, gall bladder and pancreas

Performed on an outpatient basis, EUS is well-tolerated by most people and may ultimately help in lowering healthcare costs and complications in patients.

While EUS had been primarily limited to identification of pancreatic malignancies, its diagnostic and therapeutic scope has evolved over the years to cover a variety of diseases and indications. According to Mayo Clinic, EUS may help in the assessment of the following conditions:

  • Cancer of the colon, esophagus, lung, pancreas or stomach, and ampullary and rectal cancers
  • Lymphoma
  • Barrett’s esophagus
  • Neuroendocrine tumors
  • Pancreatitis and pancreatic cysts
  • Bile duct stones
  • Sarcoidosis

EUS can be used to:

  • Assess the extent to which a tumor has penetrated the abdominal wall in esophageal, gastric, rectal, pancreatic and lung cancers
  • Establish the stage of cancer
  • Determine if cancer has metastasized to the lymph nodes or other organs
  • Provide precise information to guide treatment of non-small cell lung cancer cells
  • Evaluate abnormal findings from imaging tests (e.g., cysts of the pancreas)
  • Guide drainage of pseudocysts and other abnormal accumulation of fluid in the abdomen
  • Allow precise delivery of medication directly into the pancreas, liver and other organs

2018 CPT Codes for EUS Services

The American Society for Gastrointestinal Endoscopy (ASGE) has developed CPT codes for EUS-related procedures, tests and visits. The work for GI EUS such as supervision and interpretation and guidance for needle placement, supervision and interpretation is bundled into the EUS codes themselves. The EUS CPT codes for 2018 are as follows:

  • 43231 Esophagoscopy, flexible, transoral; with endoscopic ultrasound examination
  • 43232 Esophagoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine-needle aspiration/biopsy(s)
  • 43237 Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures
  • 43238 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine-needle aspiration/biopsy(s), (includes endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures)
  • 43240 Esophagogastroduodenoscopy, flexible, transoral; with transmural drainage of pseudocyst (includes placement of transmural drainage catheter[s]/stent[s], when performed, and endoscopic ultrasound, when performed)
  • 43242 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine-needle aspiration/biopsy(s), (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis)
  • 43253 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided transmural injection of diagnostic or therapeutic substance(s) (eg, anesthetic, neurolytic agent) or fiducial marker(s) (includes endoscopic ultrasound examination limited to the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis)
  • 43259 Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination, including the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis
  • 44406 Colonoscopy through stoma; with endoscopic ultrasound examination, limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures
  • 44407 Colonoscopy through stoma with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures
  • 45341 Sigmoidoscopy, flexible; with endoscopic ultrasound examination
  • 45342 Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine-needle aspiration/biopsy(s)
  • 45391 Colonoscopy, flexible; with endoscopic ultrasound examination, limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures
  • 45392 Colonoscopy, flexible; with transendoscopic ultrasound-guided intramural or transmural fine-needle aspiration/biopsy(s), (includes endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures)

The ASGE’s code sheet also provides the following summary of upper GI EUS Code distinctions

Visual Endoscopy Extent EUS Extent Code to report EUS/FNA Extent Code to report
Esophagus Esophagus 43231 Esophagus 43232
Esophagus, stomach, duodenum/jejunum Esophagus, stomach, OR duodenum/jejunum 43237 Esophagus, stomach, OR duodenum/jejunum 43238
Esophagus, stomach, duodenum/jejunum Esophagus, stomach, AND duodenum/jejunum 43259 Esophagus, stomach, AND duodenum/jejunum 43242

Moderate Sedation and Anesthesia Codes

Starting January 1, 2017, moderate sedation was removed from the relative value units (RVUs) for gastrointestinal endoscopy services. If moderate (conscious) sedation is provided when performing GI procedures, moderate sedation should be billed separately using appropriate moderate sedation HCPCS code(s): 99151, 99152, +99153, 99155, 99156, +99157 and G0500. Failure to do so will result in loss of reimbursement for these services.

In 2018, five codes were added for anesthesia for gastro-endoscopic procedures and three low-volume codes (01180, 01190, and 01682)were deleted. The five new CPT codes are:

  • 00731 – Anesthesia Upper GI Endoscopy (EGD, EUS, Enteroscopy, Secretin Stimulation Test)
  • 00732 – Anesthesia Upper GI Endoscopy (ERCP)
  • 00811 – Anesthesia Lower GI Endoscopy (Colonoscopy, Ileoscopy)
  • 00812 – Anesthesia Lower GI Endoscopy (screening colonoscopy)
  • 00813 – Anesthesia for combined upper and lower GI Endoscopic procedures.
  • 00813 – Anesthesia for combined upper and lower GI Endoscopic procedures

Actual reimbursement for gastroenterology procedures will vary for each provider/institution based on factors such as geographic differences in labor and non-labor costs, hospital teaching status, and/or proportion of low-income patients. Experienced medical billing and coding company help practices can ensure fair and reasonable reimbursement by reporting EUS with the appropriate codes and in accordance with individual payer policies.