CPT Code 43239 Esophagogastroduodenoscopy

43239 Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple

43239 with biopsy, single or multiple 

GI Procedures

EGD Procedures 

• Use code 43235 for a Diagnostic EGD procedure. Since this is classified as a “Separate Procedure” in the CPT book, it is not billable when a more extensive EGD procedure is performed.

• Two Upper Gastrointestinal Endoscopy procedures such as code 43239 for Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple and code 43245 for Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum, as appropriate; with dilation of gastric outlet for obstruction (e.g., balloon, guidewire, bougie) performed at the same setting would both be billable.

• If an EGD is done to collect a specimen for a CLO/H. Pylori test, since the test involves obtaining a tissue biopsy through the endoscope, the 43239 Biopsy code should be used. If the test is positive, the diagnosis code 041.86 for Helicobacter pylori (H. pylori) infection would be billed.

• 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 scope with biopsy and code 43450 for the Esophageal Dilation would both be billed.

• Use CPT code 43248 if the patient has an EGD procedure with a flexible-tipped guidewire passed through the endoscope, the endoscope is withdrawn and the guidewire is left in place for dilators to be passed over the guidewire to dilate the Esophagus. If the guidewire is passed under fluoroscopic guidance for esophageal dilation, without the use of an endoscope, use CPT code 43453. 

• The control of bleeding is included in biopsy (and most other) endoscopic procedures, and is not separately-billable. Control of bleeding can be obtained through means of injections, as well as cauterizations. Injections of Epinephrine through an endoscope are coded as 43255. This injection would be included in the ASC facility fee, and would not be reimbursed separately from the EGD procedure, unless the EGD case is completed and the patient is in the PACU and has a bleed, necessitating a return to the OR to treat the hemorrhage. 

• For an EGD with a Polypectomy done by Cold Biopsy Forceps, use the 43258 Ablation code – not the 43239 Biopsy code. 

Endoscopy codes

Question and Answer Forum

Question: Do codes 43239 and 43255 require modifier 59? Which do I bill first, and to which code do I attach the modifier?

Answer: If the primary purpose of the endoscopy was control of bleeding, and a separate lesion/site was found, which required biopsy, then 43255 would be reported first; 43239 with 59 modifier would be reported for the second service, which would otherwise be bundled (i.e., biopsy of the bleeding site would not be separately reportable). If bleeding resulted from biopsy of a lesion and the treatment was for this purpose, the bleeding control would be considered part of the procedure (43239) and thus, 43255 would not be separately reported.

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).

Q: Can we code a 43239 with a 43249? I'm not sure if 43239 is included in 43249.

A: CPT guidelines permit the reporting of multiple endoscopy codes as appropriate. Codes 43239 and 43249 describe distinctly different procedures and should not be bundled by the payers. Both codes however include an upper GI endoscopy and payment adjustments should be expected for the duplicative portion. The issue becomes one of bundling - that is, is one code "bundled" in another by the payer? With the exception of Medicare, each carrier (Cigna, Aetna, Humana, etc.) has its own edits regarding bundling. There is no "national" bundling book for us to check in other than Medicare's Correct Coding Initiative (CCI). Under the CCI, these procedures are not bundled. I suggest that you report both services and monitor the EOB. If they are denied, I would appeal by referring to the distinct nature of the services and the CCI. It is helpful to have distinct ICD-9 codes (if appropriate) for the services to support the need for both of them on the same patient.

Upper GI Endoscopy with Biopsy CPT - 43239 

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