2011-06-30 15:54:05 UTC

Reaching the Lower Duodenum: 43235 or 44360?

July 8, 2011

Since the definition of small bowel endoscopy or enteroscopy is beyond the second portion of the duodenum, does that mean that any time the scope goes further than that, you can automatically bill for small bowel endoscopy? Unfortunately, no.

By Kathleen A. Mueller, RN, CPC, CCS-P, CMSCS, CCC, PCS

For as long as upper GI endoscopy codes have existed, choosing the correct code for upper endoscopy that reaches the duodenum has been a problem for coders. Upper GI endoscopy/esophagogastroduodenoscopy (EGD) codes start with the 43235 series, and small bowel endoscopy/enteroscopy codes start with the 44360 series. When reading through the endoscopy report, you often see that the scope was inserted past the second portion of the duodenum. Since the definition of small bowel endoscopy or enteroscopy is beyond the second portion of the duodenum, does that mean that any time the scope goes further than that, you can automatically bill for small bowel endoscopy? Unfortunately, no. In order to understand why that is possible, we need to look at the lengths of each part of the small intestine. It is divided into three structural parts:

  • Duodenum: 25 cm (9.84 in) in length
  • Jejunum: 2.5 m (8.2 ft) in length
  • Ileum: 3.5 m (11.5 ft) in length

Since the duodenum is less than a foot in length, it does not take much more scope to go beyond the second portion. Just because the physician went further than intended, does not mean that the enteroscopy category should be chosen. The intent of the procedure should dictate what code you should choose. Often, patients are undergoing enteroscopy because of unproven anemia, blood loss, malabsorption, possible Crohn's or neoplastic disease. Usually, a previous endoscopic work-up involving both the upper and lower intestinal tract has been negative. It is possible to bill enteroscopy — even when the intent of the procedure was for EGD — if extensive disease was found in the proximal duodenum, prompting the gastroenterologist to investigate further. The diagnosis code(s) submitted on this claim should back up enteroscopy. Usually peptic ulcer disease, GERD or achalasia would not support the enteroscopy code and may prompt payors to initially deny the claim.

When reading through the endoscopic report, look for the type of scope that is being used on this patient. Often, patients undergoing intended enteroscopy will have the pediatric colonoscope inserted and not the gastroscope. However, coders should not simply rely on the equipment utilized since this might be the equipment of choice for some gastroenterologists. The bottom line is: if you are unsure, communicate with your physician since the note might need to be amended prior to claim submission.

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