tci General Surgery Coding Alert - 2001 Issue 5

Documentation Makes the Difference When Coding Upper GI Endoscopies

Any of more than 20 CPT codes may best describe an upper gastrointestinal (GI) procedure. Accurate coding depends on knowing exactly what the surgeon did and the final destination of the scope. Additionally, if more than one endoscopy is performed during the same session, the coder must know when HCFAs multiple-endoscopy rule applies and how payment for the operative session may be affected. Although some upper GI procedures, such as endoscopic retrograde cholangiopancreatography (ERCP), are mainly performed by gastroenterologists, many general surgeons perform other GI endoscopic procedures, such as esophagogastroduodenoscopy (EGD), percutaneous endoscopic gastrostomy (PEG) tube placement, biopsies and...

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