tci General Surgery Coding Alert - 2015 Issue 5

You Be the Coder: Beware Bundled EGD Services

Question: If the surgeon performs an EGD with biopsy, and documents control of bleeding during the procedure and the highest level inpatient E/M on the same day, which services can I bill? California Subscriber Answer: At minimum, you should bill the EGD with biopsy as 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple). Whether you can separately bill for the bleeding control and the E/M service depends on the circumstances and your surgeon’s documentation. Bleeding control: When bleeding occurs as a result of an endoscopic procedure, you should not separately report a code for control of bleeding...

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