Monday, June 21, 2010

Coverage and Indication of EGD (Esophagogastroduodenoscopy and Therapeutic EGD)

Upper Gastrointestinal Endoscopy With/Without Ultrasound

Indications and Limitations of Coverage and/or Medical Necessity
Indications for Diagnostic Esophagogastroduodenoscopy (EGD(s))
  • 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).
  • X-ray findings of:
    • A suspected neoplastic lesion, for confirmation and specific histologic diagnosis.
    • Gastric or esophageal ulcer.
    • 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 aortoenteric fistula is suspected.
    • 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.
  • Intraoperative EGD when necessary to clarify location or pathology of a lesion.

Indications for Therapeutic EGD(s)

  • 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.
  • Placement of feeding tubes (peroral, percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy).
  • Dilation of stenotic lesions (e.g., with transendoscopic balloon dilators or dilating systems employing guide wires).
  • Palliative therapy of stenosing neoplasms (e.g., laser, bipolar electrocoagulation, stent placement).
  • Botox injections for achalasia.

Coverage Limitations for EGD(s)

  • Distress that is chronic, non-progressive, atypical for known organic disease and is considered functional in origin (there are occasional exceptions in which an endoscopic examination may be done once to rule out organic disease, especially if symptoms are unresponsive to therapy).
  • Uncomplicated heartburn responding to medical therapy.
  • Metastatic adenocarcinoma of unknown primary site when the results will not alter management.
  • X-ray findings of:
    • Asymptomatic or uncomplicated sliding hiatus hernia.
    • Uncomplicated duodenal bulb ulcer that has responded to therapy.
  • Deformed duodenal bulb when symptoms are absent or respond adequately to ulcer therapy.
  • Routine screening of the upper gastrointestinal tract, without current gastrointestinal symptoms, about to undergo elective surgery for non-upper gastrointestinal disease.
  • When lower GI endoscopy reveals the cause of symptoms, abnormal signs or laboratory tests (e.g., colonic neoplasm with iron deficiency anemia). Exceptions can be considered if medical necessity for this procedure can be demonstrated.
Coverage Limitations for Sequential or Periodic Diagnostic EGD(s)
  • Surveillance for malignancy in patients with gastric atrophy, pernicious anemia, treated achalasia or prior gastric operation.
  • Surveillance of healed benign disease such as esophagitis, gastric or duodenal ulcer.
  • Surveillance during chronic repeated dilations of benign strictures unless there is a change in status.
    Note: See ?Utilization Guidelines? below for frequency specifics.
Endoscopic Ultrasonography
Endoscopic ultrasonography obtains structural information about the gastrointestinal tract and the tissues immediately surrounding it not available by any other non-invasive means. The ultrasound transducer is placed adjacent to the target area, allowing for the use of high ultrasound frequencies (5?20 MH 2) that provide detailed studies of the GI wall and adjacent structures.

Endoscopic ultrasonography is covered for staging and follow-up of primary and secondary neoplasms in patients with cancer of the esophagus, stomach and the pancreas when the information could alter the patient?s medical management.

They are also covered for evaluation of submucosal abnormalities of the esophagus, stomach and duodenum when it is difficult to differentiate between neoplasm, vascular lesion or cystic lesion, and the information could alter the patient?s medical management.
Note: Type of Bill and Revenue Codes DO NOT apply to Part B.

Coverage Topics
Diagnostic Tests and X-Rays
Surgical Services
Type of Bill Codes
12X, 13X, 18X, 21X, 83X, 85X
Revenue Codes
Note: TrailBlazer has identified the Type of Bill (TOB) and Revenue Center (RC) codes applicable for use with the CPT/HCPCS codes included in this policy. Providers are reminded that not all the CPT/HCPCS codes listed can be billed with all TOB and/or RC codes listed. CPT/HCPCS codes are required to be billed with specific TOB and RC codes. Providers are encouraged to refer to the CMS Internet-Only Manual IOM) Pub. 100-04 Claims Processing Manual for further guidance.
036X, 045X, 049X, 075X, 0761

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