BREAKING IT DOWN: EGD WITH ENDOSCOPIC ULTRASOUND

January 31, 2020

Breaking It Down: EGD with Endoscopic Ultrasound

Esophagogastroduodenoscopies with endoscopic ultrasound examination can appear rather confusing, especially when additional procedures such as fine needle aspirations or injections of adjacent structures are also performed in tandem with the original procedure.

The first thing to remember is that all of the Upper EUS codes are subsets of the parent code, 43235 Esophagogastroduodenoscopy.  If you look at the code book, all of the codes under 43235 start with “with”.  Keeping this in mind, you will realize it is always assumed that an entire EGD has been performed (esophagus, stomach, 2nd portion of duodenum) prior to the insertion of the echoendoscope.  Also note that there is a separate code for esophagoscopy with EUS, meaning the stomach and/or duodenum is not entered with the scope.

For the purpose of the EGD’s with EUS, the GI system is broken down into three basic regions:

  1. Esophagus
  2. Stomach
  3. Duodenum (or surgically altered stomach where the jejunum is examined distal to the anastomosis)

The next thing to distinguish is the subtle verbiage differences in the code descriptions, namely AND versus OR, which helps identify the best code for the operative scenario.  For these procedures, the word “and” (esophagus, stomach, AND either duodenum or surgically altered stomach…) means that all three regions have to be evaluated using ultrasound.  When “OR” is used, the intent is to reflect that two out of the three regions are evaluated.  Typically, 43237 is used when the EUS probe is inserted through the esophagus and into the stomach, but does not reach the duodenum. 

Of note, it is also assumed that adjacent structures are always visualized during an ultrasound, even though the only codes that specifically state “and adjacent structures” are 43237 and 43238.  Adjacent structures is defined as not only the walls of the GI tract, but other structures such as the liver, biliary tract, pancreas, lymph nodes.

When determining the correct code assignment, remember that the code descriptions for endoscopic ultrasound refer specifically to the ultrasound probe, and the depth to which it is inserted.  A complete esophagogastroduodenoscopy has to be performed prior to the EUS in order to correctly choose a code from this section as evidenced by the code format contained in the CPT book.

CODES WITH THEIR DEFINITIONS:

43235 Esophagogastroduodenoscopy
43237 with EUS limited to esophagus, stomach or duodenum and adjacent structures
43238 with EUS with fine needle aspiration (Includes EUS limited to esophagus, stomach, or duodenum and adjacent structures)
43242 with EUS with FNA (includes EUs of esophagus, stomach, and either duodenum or surgically altered stomach where the jejunum is examined distal to the anastomosis)
43253 with EUS guided transmural injection of diagnostic or therapeutic substance (includes EUS exam of esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis)
43259 with EUS including the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis

For additional uses for EUS, check out Excellent Endoscopy.

Robyn McCoart, RHIT

Managing Auditor, Excite health Partners