AMA Clinical Examples in Radiology - 2019 Issue 4 (Fall)
Fluoroscopic Upper Gastrointestinal and Small Bowel Study
CLINICAL EXAMPLE 1 Fluoroscopic Upper Gastrointestinal and Small Bowel Study CLINICAL HISTORY The patient, with recent diagnosis of inflammatory bowel disease, had a three-week history of abdominal pain, weight loss, and fever. Initial computed tomography (CT) scan in the emergency department demonstrated extensive bowel wall thickening and inflammatory changes involving the distal small bowel. The patient subsequently underwent esophagogastroduodenoscopy (EGD) and colonoscopy, which demonstrated esophageal ulcers, gastritis, scattered colonic ulcers, and an inflamed terminal ileum. Upper gastrointestinal (GI) examination with small bowel follow-through was requested for evaluation of any possible small bowel strictures or fistulas. TECHNIQUE Barium was administered...
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Article Overview
This article explains a radiology clinical example involving an upper GI exam with small bowel follow-through, along with associated coding guidance for CPT, ICD-10-CM, and HCPCS Level II. It is aimed at coders and billing professionals who need to understand how the study is classified, how the applicable code family changed for dates of service on or after January 1, 2020, and how fluoroscopy documentation affects reporting. The discussion also references professional coding organizations and MIPS-related documentation requirements.
Why This Topic Matters
Radiology coding for fluoroscopic GI studies changed during the 2020 CPT update, so understanding the article helps support accurate reporting and compliance across service dates. It also highlights the importance of complete fluoroscopy documentation in meeting quality reporting expectations.
Article Sections
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Clinical Example 1
A radiology clinical scenario is presented with history, technique, findings, and impression for an upper GI study with small bowel follow-through.
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How to Code
Coding guidance is provided for different dates of service, including the related diagnostic code and fluoroscopy documentation considerations.
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Discussion
The discussion summarizes the broader coding context, including CPT changes, HCPCS reporting, and references to professional organizations and quality reporting programs.
What You Will Learn
- What the article covers in a fluoroscopic upper GI and small bowel study case
- How the coding guidance is organized by date of service
- Which coding systems are discussed in the article
- What documentation themes are emphasized for fluoroscopy-based reporting
- Which organizations and coding update resources are referenced
Who Should Read This
- Medical coders
- Radiology billing staff
- Compliance professionals
- Physician documentation specialists
- Revenue cycle teams
Codes Discussed
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