tci General Surgery Coding Alert - 2016 Issue 9

Reader Question: Capture EGD Dilation and Biopsy

Question: Our surgeon performed an EGD that required dilation for access. Upon examination of the duodenum, the surgeon biopsied a suspicious lesion. How should we bill this? Tennessee Subscriber Answer: You can bill for both the Esophagogastroduodenoscopy (EGD) dilation and biopsy by reporting 43248 (Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator[s] through esophagus over guide wire) and 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple). There is no Correct Coding Initiative (CCI) edit that restricts reporting these two codes together, and although CPT® instruction restricts you from reporting many codes in addition...

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