Saturday, June 18, 2016

Upper Gastrointestinal Endoscopy CPT code 43259, 43234, 43235









43234 Upper gastrointestinal endoscopy, simple primary examination (e.g., with small diameter flexible endoscope)

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

  Digestive System (Codes 40000 - 49999)

A. Upper Gastrointestinal Endoscopy Including Endoscopic Ultrasound (EUS) (Code 43259)

If the person performing the original diagnostic endoscopy has access to the EUS and the clinical situation requires an EUS, the EUS may be done at the same time. The procedure, diagnostic and EUS, is reported under the same code, CPT 43259. This code conforms to CPT guidelines for the indented codes. The service represented by the indented code, in this case code 43259 for EUS, includes the service represented by the unintended code preceding the list of indented codes. Therefore, when a diagnostic examination of the upper gastrointestinal tract “including esophagus, stomach, and either the duodenum or jejunum as appropriate,” includes the use of endoscopic ultrasonography, the service is reported by a single code, namely 43259 Interpretation, whether by a radiologist or endoscopist, is reported under CPT code 76975-26. These codes may both be reported on the same day.


Oxford insurance Guidelines

Virtual upper gastrointestinal endoscopy is unproven and not medically necessary for detecting and evaluating upper gastrointestinal lesions due to insufficient clinical data from the peer-reviewed published medical literature to conclude that virtual upper gastrointestinal endoscopy is effective.

A limited number of studies of virtual upper gastrointestinal endoscopy have been published. Most studies involve a small number of patients and lack definitive patient selection criteria. Many of the studies have a serious shortcoming in that they assessed patients who were known or strongly suspected to have cancer or other upper gastrointestinal (GI) lesions. As a result, these studies may have overestimated the sensitivity of virtual endoscopy for gastric cancer detection. Randomized controlled studies comparing virtual upper GI endoscopy to conventional upper GI endoscopy are needed.

Virtual upper gastrointestinal endoscopy is a noninvasive procedure that uses three-dimensional imaging and computed tomography (CT) to capture detailed pictures of the inside surfaces of organs [e.g., organs of the gastrointestinal (GI) tract]. Magnetic resonance imaging (MRI) can also be used to perform virtual upper GI endoscopy. Virtual endoscopy is thought by some to be useful in determining the cause of symptoms such as nausea, gastric reflux, abdominal pain, unexplained weight loss, and identifying inflammation, ulcers, precancerous conditions, and hernias.

Patients undergoing a virtual upper gastrointestinal endoscopy usually do not need anesthesia or sedation. Another advantage is that upon procedure completion, physicians have the capability to modify the captured pictures by magnifying the images or altering the image angles. Disadvantages of virtual upper gastrointestinal endoscopy include the difficulty in showing fine detail compared to a standard endoscopy procedure; exposure to CT scan radiation, and the inability to biopsy during the procedure. (If a lesion is found, conventional upper GI endoscopy is necessary for excision or biopsy.

Qumseya et al. (2013) conducted a meta-analysis and systematic review to prospectively compare the use of both virtual chromoendoscopy and chromoendoscopy with white-light endoscopy (WLE) and collection of random biopsies for surveillance of patients with Barrett's esophagus (BE) to detect dysplasia. Fourteen studies with a total of 843 patients were included in the final analysis. It was noted that though white-light endoscopy (WLE) and collection of random biopsies is the recommended mode of surveillance, this approach does not definitively or consistently detect areas of dysplasia. It was surmised that advanced imaging technologies can increase detection of dysplasia and cancer. Results showed overall, that the advanced imaging techniques increased the diagnostic yield for detection of dysplasia or cancer by 34%. There was no noted significant difference between virtual chromoendoscopy and chromoendoscopy, based on Student t test analysis. Though the virtual chromoendoscopy compared favorable to the conventional chromoendoscopy, there was no evidence to show that virtual imaging was superior to the conventional study in any way. Additional randomized controlled studies comparing virtual upper GI endoscopy to conventional upper GI endoscopy are needed.

Chen et al. (2009) retrospectively compared the use of computed tomographic virtual gastroscopy (VG) to conventional optical gastroendoscopy when determining differences between benign and malignant gastric ulcers.

Gastric ulcers in 115 patients (mean age, 64.7 years; range, 31-86 years; 61 men, 54 women) were evaluated by using endoscopy and VG. At histopathologic examination, 39 gastric ulcers were benign, while 76 were malignant. VG and endoscopy had sensitivities of 92.1% (70 of 76) and 88.2% (67 of 76), respectively, for overall diagnosis of malignant gastric ulcers, and specificities of 91.9% (34 of 37) and 89.5% (34 of 38), respectively, for overall diagnosis of malignant gastric ulcers. Endoscopy was more sensitive in depicting malignancy according to ulcer base [85.5% (65 of 76) vs 68.4% (52 of 76)], and VG was more specific in depicting malignancy according to ulcer margin [78.4% (29 of 37) vs 63.2% (24 of 38)]. The authors concluded that VG and endoscopy were almost equally useful in distinguishing between malignant and benign gastric ulcers. These findings need confirmation in a larger study.

The reviewed studies all have a serious shortcoming in that they assessed patients who were known or strongly suspected to have cancer or other gastric lesions. As a result, these studies may have overestimated the sensitivity of virtual endoscopy for gastric cancer detection. For the detection of early gastric carcinoma, the lower sensitivity of virtual endoscopy relative to conventional imaging techniques has significant clinical implications. Randomized controlled studies comparing it to conventional upper GI endoscopy are needed to determine its clinical value.

B. Incomplete Colonoscopies (Codes 44388, 45378, G0105 and G0121)

An incomplete colonoscopy, e.g., the inability to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, is billed and paid using colonoscopy through stoma code 44388, colonoscopy code 45378, and screening colonoscopy codes G0105 and G0121 with modifier “-53.” (Code 44388 is valid with modifier 53 beginning January 1, 2016.) The Medicare physician fee schedule database has specific values for codes 44388-53, 45378-53, G0105-53 and G0121-53. An incomplete colonoscopy performed prior to January 1, 2016, is paid at the same rate as a sigmoidoscopy. Beginning January 1, 2016, Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes.

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