Esophagogastroduodenoscopy (EGD) or upper gastrointestinal endoscopy is an important element in gastroenterology medical billing. EGD is a procedure that involves the introducing a small, flexible endoscope (through the mouth or with smaller endoscopes, through the nose) for visualization of the oropharynx, esophagus, stomach, and proximal duodenum, including real-time evaluation and interpretation of the findings. Medical billing and coding outsourcing companies work to ensure that gastroenterology practices report EGD correctly for appropriate reimbursement.
Overview of EGD
EGD has both diagnostic procedures and therapeutic functions, that is, the technique is utilized to examine or obtain samples, and also to treat abnormalities.
Diagnostic EGD: A diagnostic EGD allows the physician to make diagnostic observations regarding focal benign or malignant lesions, diffuse mucosal changes, luminal obstruction, motility, and extrinsic compression by contiguous structures. It allows visualization of abnormalities detectable by the technique and to photograph, biopsy, and/or remove lesions as appropriate.
Indications that support EGD(s) for diagnostic conditions:
- Patient has upper abdominal distress (e.g., gastroesophageal reflux disease) which persists despite an appropriate trial of symptomatic therapy;
- Patient has upper abdominal distress associated with a short history of signs and symptoms suggesting significant associated disease or illness (e.g., weight loss, anorexia, vomiting, nonsteroidal anti-inflammatory drug [NSAID] intake, other gastric irritant intake);
- Patients over the age of 40 who have experienced a significant history of heartburn that returns after a course of symptomatic therapy;
- Patients who have dysphagia or odynophagia;
- Patient has persistent, unexplained vomiting;
- Patient has upper gastrointestinal x-ray findings of: any lesion that requires biopsy for diagnosis; or gastric ulcer suspicious of cancer; or evidence of stricture or obstruction;
- To assess acute injury after caustic agent ingestion;
- When anti-reflux surgery is contemplated; or
- Patient has gastrointestinal bleeding: in most actively bleeding patients; or for presumed chronic blood loss and iron deficiency anemia when investigation of large bowel is negative.
Therapeutic EGD: Applications of therapeutic EGD include: managing haemorrhage, removing foreign bodies and neo plastic growths, relieving obstruction due to stricture, malignancy, or other causes through dilatation or the placement of stents, and to assist in the placement of percutaneous gastrostomy tubes.
EGD(s) will be considered medically reasonable and necessary for the following therapeutic purposes:
- Treatment of bleeding lesions;
- Removal of foreign bodies;
- Sclerotherapy and/or band ligation for bleeding from esophageal or gastric varices;
- Dilatation of strictures in the upper intestinal tract;
- Removal of selected polypoid lesions;
- Placement of feeding tubes;
- Palliative therapy of stenosing neoplasms (e.g., laser, stent placement).
Follow-up EGD(s): Indications that support follow-up EGD(s) are –
- Biopsy surveillance of patients with Barrett’s esophaguse very 12 to 24 months (if dysplasia is present, earlier surveillance intervals of from three to six months may be required);
- Follow-up of gastric ulcers to healing or satisfaction that they are benign;
- Follow-up and treatment of esophageal strictures requiring guide wire dilation;
- Follow-up of duodenal ulcer or other lesions of the upper gastrointestinal tract that have resulted in serious consequences (e.g., hemorrhage);
- Follow-up of patients having a previous gastric polypectomy for adenoma; or
- Follow-up and treatment of patients with esophagealvarices or bleeding lesions requiring recurrent therapy (e.g., esophagealvarices, gastric varices, angiodysplastic or watermelon stomach lesions, radiation gastritis);
- Follow-up for removal of percutaneous gastrostomy tube (PEG)
Situations where periodic EGD is NOT usually indicated –
- Surveillance of healed, benign disease such as gastric or duodenal ulcer or benign esophageal strictures; or
- Cancer surveillance in patients with pernicious anemia, treated achalasia, or prior gastric resection.
EGD is generally contraindicated for patients with recent myocardial infarction.
2018 CPT/HCPCS Codes for Esophagogastroduodenoscopy
The CPT codes to report services performed during an esophagogastroduodenoscopy are:
43233 Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed)
43235 Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed
43236 Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance
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)
43239 Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple 43241 Esophagogastroduodenoscopy, flexible, transoral; with insertion of intraluminal tube or catheter 43243 Esophagogastroduodenoscopy, flexible, transoral; with injection sclerosis of esophageal gastric varices
43244 Esophagogastroduodenoscopy, flexible, transoral; with band ligation of esophageal gastric varices
43245 Esophagogastroduodenoscopy, flexible, transoral; with dilation of gastric/duodenal stricture(s) (eg, balloon, bougie)
43246 Esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube
43247 Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body(s)
43248 Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire
43249 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter)
43250 Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
43251 Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
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 of the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis)
43254 Esophagogastroduodenoscopy, flexible, transoral; with endoscopic mucosal resection
43255 Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method
43266 Esophagogastroduodenoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)
43270 Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)
EGD is typically done in a dedicated endoscopy unit in the hospital or outpatient office setting but can also performed in the emergency department (ED), the intensive care unit (ICU), or the operating room, or using portable endoscopy carts. The valid CPT code should be reported along with a revenue code to inform the insurance company as to whether the procedure was performed in the emergency room, operating room or another department. The revenue codes for EGD are:
360 Operating Room Services, General Classification
361 Operating Room Services, Minor Surgery
750 Gastro-Intestinal Services, General Classification
ICD-10 Codes that Support Medical Necessity
Claims for payment should be accompanied by the diagnosis codes to help support the medical necessity of the procedure. Examples of ICD 10 codes that support medical necessity for EGD include:
B25.2 Cytomegaloviral pancreatitis
B37.81 Candidal esophagitis
C15.3- C15.9 Malignant neoplasm of esophagus
D12.0-D12.9 Benign neoplasm of colon, rectum, anus and anal canal
E16.4 Increased secretion of gastrin E16.9 Disorder of pancreatic internal secretion, unspecifiedF50.00-F50.02 Anorexia nervosa
I85.10-I85.11 Secondary esophagealvarices
J69.0 Pneumonitis due to inhalation of food and vomit
J86.0 Pyothorax with fistula
K20.0-K22.8 Diseases of esophagus, stomach and duodenum
M34.0-M34.9 Systemic sclerosis [scleroderma]
Q26.5-Q26.6 Congenital malformations of great veins
R10.84 – R10.9 Abdominal and pelvic pain
T86.40-T86.49 Complications of liver transplantZ85.068-Z85.09 Personal history of malignant neoplasm of digestive organs
Anesthesia for GI Endoscopic Procedures – CPT Changes in 2018
A variety of sedatives and analgesics can be used to achieve appropriate levels of sedation for GI endoscopic procedures. The targeted level of sedation generally varies based on patient and procedural variables. The levels of sedation for GI endoscopic procedures are: minimal sedation, moderate sedation, deep sedation and general anesthesia. In 2018, there are significant changes in anesthesia related endoscopic procedures:
- Two CPT codes deleted: CPT codes 00740 upper GI endoscopic procedures and 00810 for lower GI endoscopic procedures have been deleted in 2018.
- Five CPT codes added:
00731 – Upper GI – endoscope, proximal to duodenum
00732 – Upper GI – endoscope, endoscopic retrograde cholangiopancreatography (ERCP)
00811 – Lower GI – endoscope, distal to duodenum
00812 – Lower GI – endoscope, screening colonoscopy
00812 – Upper and Lower GI – endoscope, both proximal to and distal to the duodenum
The ordering/referring physician must clearly indicate the reason for the EGD in the patient’s medical record. The results of the EGD must also be available in the patient’s medical record.
To assign the correct codes, skilled medical coders will examine the documentation to understand exactly what the surgeon did and the final destination of the scope. They are also well versed in the use of modifiers and billing guidelines pertaining to GI/endoscopy, which varies among payers. Outsourcing medical billing and coding to an experienced provider of gastroenterology medical billing services can help ensure error-free claim submission for optimal reimbursement.