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Coding Case Study Focuses on Digestive System Procedures

Preoperative Diagnosis: Gastrointestinal (GI) bleeding, unspecified

Procedure Performed: EGD with electrocautery to control hemorrhage from AVMs

Indication for Procedure: This patient is a 79-year-old black female who has had evidence for GI bleeding with a drop in her hemoglobin and hematocrit values and black stools, consistent with an upper GI source.

Operative Technique: Following informed consent, the patient was taken to the endoscopy suite and placed in the left lateral decubitus position. Continuous monitoring of heart rate and oxygen saturation was performed with automatic devices throughout the procedure. Conscious sedation and topical anesthesia were obtained.

The endoscope was introduced easily under direct vision and passed through the lumen of the esophagus, stomach and duodenum with adequate visualization. The esophagus was endoscopically intact. The scope passes easily through the distal esophagus and on into the stomach.

The stomach is examined, including retroflex view, and reveals a mild diffuse gastritis remarkable for punctate and minute hemorrhages scattered through the fundus, body and antrum. No significant bleeding was noted, however. Biopsies were taken of these areas to rule out H. pylori infection. There were no ulcerations or other mucosal defects.

The endoscope passes easily through the pylorus, and the duodenum is examined throughout the second portion. This is remarkable for two AVMs located in the bulb of the duodenum, anteriorly. These are not actively bleeding but considered as potential sites for blood loss, and bicap cautery is applied to them sequentially. For each lesion, two applications of bicap cautery were applied for three to four seconds each at a second of three and continuous.

Good hemostasis was noted. Subsequently, on slow withdrawal of the scope, careful examination was again made of the mucosa of the upper GI tract, and no additional lesions are appreciated.

The patient tolerated the procedure well and is returned to recovery in stable and alert condition without complications.

Postoperative Diagnosis: Mild gastritis with punctate hemorrhages, biopsied to rule out H. pylori; and duodenum with two AVMs noted, potential bleeding sites and cauterized with bicap cautery.

Code Assignments and Rationale
In the above case study, the surgeon used bicap cautery to endoscopically control bleeding from AVMs. This control may be achieved using several endoscopic methods, including laser therapy, electrocoagulation, rubber band ligation or injection of the bleeding vessel with clerosants, ethanol or adrenaline.

In the index of the 2000 CPT manual, look up the terms Endo-scopy, Gastrointestinal, Upper and Hemorrhage. The description will confirm that one appropriate code assignment for the facility component is 43255.

43255 Upper GI endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; with control of bleeding, any method

The surgeon also took some biopsies from several areas of the stomach due to the patient’s gastritis. In the CPT index, look for the terms Endoscopy, Gastrointestinal, Upper and Biopsy. The description confirms that the appropriate assignment, for both the facility and professional components, is code 43239.

43239 Upper GI endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple

Because the preoperative and postoperative diagnoses differ, so do the ICD-9-CM codes assigned. For the preoperative assignment, you would assign code 578.9 (GI hemorrhage, unspecified).

The following two ICD-9-CM codes are appropriate for the postoperative assignment.

535.40 Other specified gastritis, without mention of hemorrhage

537.83 Angiodysplasia of stomach and duodenum with hemorrhage *

Peggy Hapner is a senior health care consultant for Medical Learning Inc. (MedLearn®), St. Paul, MN.

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