Vol. 13 •Issue 12 • Page 9
Coding Corner
Digestive System Coding Exercise
Case Study One
Preoperative Diagnosis: Mass lesion of soft palate at the right retromolar trigone
Postoperative Diagnosis: Mass lesion of soft palate at the right retromolar trigone
Procedure Performed: Excision of mass lesion
Operative Technique: After adequate general anesthesia was obtained, an incision was made overlying the 1.0 cm cystic mass of the soft palate at the retromolar trigone. The incision was made overlying the mass. By sharp and bluntdissection with the Metzenbaum scissors, the cystic mass was circumferentially dissected from the surrounding tissue and excised en bloc and intact. It was sent to the pathology department.
Hemostasis was obtained with two figure-eight suture ligatures of 3-0 chromic catgut and cautery with the suction Bovie unit. The wound was then closed with interrupted sutures of 3-0 chromic catgut. The patient tolerated the procedure well and left the operating room in good condition.
ICD-9-CM Code Assignments
Preoperative Diagnosis: Mass lesion of soft palate at the right retromolar trigone
528.9 Other and unspecified disease of oral soft tissues
Postoperative Diagnosis: Mass lesion of soft palate at the right retromolar trigone
528.9 Other and unspecified disease of oral soft tissues
CPT Code Assignments
The surgeon states that the mass is excised en bloc and sent to pathology. The wound is then repaired with sutures.
In the CPT manual index, you should first check the terms Excision, then Lesion and Palate. The following code range is listed: 42104Ð42120. After reading the narratives of these codes, you will see that the correct code is 42106. This code should be assigned for both the facility and professional components.
42106 Excision, lesion of palate, uvula; with simple primary closure
Case Study Two
Preoperative Diagnosis:.Solid-food dysphagia
Postoperative Diagnosis: Esophagitis, gastritis, Barrett’s esophagus with stricture at 41 cm
Procedure Performed: EGD with biopsy and dilation of the esophageal stricture
Operative Technique: The patient was placed in the left lateral decubitus position. Intravenous sedation medication was given. Blood pressure, heart rate and O2 saturation were monitored continuously. A bite block was inserted.
The Olympus upper panendoscope was placed through the bite block into the hypopharynx. Under direct visualization, it was advanced down into the esophagus. Mild distal esophagitis, as well as a Barrett’s ulcer at 41 cm, were noted. A mild stricture was also noted at the site of the Barrett’s ulcer. Biopsies of this area were taken.
The scope was then advanced into the stomach, through the pylorus and into the second portion of the duodenum. The scope was then slowly withdrawn. No changes were noted in the duodenum or the pyloric area. Once the scope was brought back into the stomach, mild gastritis was noted, which was biopsied.
The scope was then withdrawn into the esophagus, where a 20-mm balloon was inserted, and the esophageal stricture was then dilated. The scope was then completely withdrawn. The patient tolerated the procedure very well and left the endoscopy suite in good condition.
ICD-9-CM Code Assignments
Preoperative Diagnosis: Solid-food dysphagia
787.2 Dysphagia
Postoperative Diagnosis: Esophagitis, gastritis, Barrett’s esophagus with stricture at 41 cm
530.19 Other esophagitis
535.50 Unspecified gastritis and gastroduodenitis
530.20 Ulcer of esophagus
530.30 Stricture/stenosis of esophagus
CPT Code Assignments
The physician states that the scope is inserted, and following inspection of the esophagus and the stomach, biopsies were taken.
In the CPT manual index, refer to the terms Endoscopy and then Gastrointestinal. Under Gastrointestinal, check under Upper, then Biopsy. Code 43239 is listed there. When you read the description, you will see that this is the appropriate code, no matter how many biopsies are taken.
The scope was still in place when the balloon was inserted to dilate the stricture. For this portion of the procedure, refer to the same three terms in the index: Endoscopy, Gastrointestinal and Upper. Under Upper, check under Dilation where the following codes are listed in the index: 43245, 43248Ð43249. After reading those code descriptions, you will see that the correct code is 43249 for the balloon dilation.
As you see below, codes 43239 and 43249 are assigned for both the facility and professional components. Note also that modifier 51, multiple procedures, should be added to the second professional code.
Facility Assignment
43239 Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple
43249 Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; with balloon dilation of esophagus (less than 30 mm diameter)
Professional Assignment
43239 Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple
43249-51 Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; with balloon dilation of esophagus (less than 30 mm diameter)
Peggy Hapner is health information management consulting division manager at Medical Learning Inc. (MedLearn®), St. Paul, MN.
