CPT Endoscopic Esophagus Procedures

Although highly developed medical technology and treatment modalities are already available in health systems in the US, further advances are constantly being made, sometimes at an alarming rate. Each year, CPT is restructured to include this progress. A large portion of the changes for FY 2014 involve GI endoscopic procedures. This discussion is going to focus on the Endoscopic Procedure of the esophagus: the anatomy, the CPT code changes, why they were made, and how professional coders will have to modify code assignment to meet new criteria.

Let’s start with the anatomy of the digestive system organs.

Anatomy of the Digestive System Organs
Let’s take a quick review of the digestive system anatomy. We are going to follow the diagram to the right and follow the digestive organs from top to bottom, (pardon the pun!).

Oral Cavity
The mouth leads to the oral cavity, which consists of a vestibule lying between the lips, the cheeks and gums (gingivae), and the teeth. The main oral cavity is found between the hard and soft palate above, the tongue and teeth below. The oral cavity leads to the pharynx which contains pharyngeal tonsils (adenoids) and palatine tonsils. Ducts of salivary glands (parotid, submandibular, and sublingual) are also in the oral cavity.

The pharynx extends from the base of the skull above to the cricoid cartilage (at the level of C6) and below. It has 3 parts: the nasopharynx (from the base of the skull above to the soft palate below), the oropharynx (from the soft palate above to the hyoid bone below), and the laryngopharynx (from the hyoid bone above to the cricoid cartilage below). The nasal cavity, oral cavity, and larynx open into the nasopharynx, oropharynx, and laryngopharynx, respectively.

The esophagus is an organ that traverses 3 regions of the body – namely, the neck, thorax, and abdomen. Therefore, it is divided into 3 parts: cervical, thoracic, and abdominal. The esophagus is a 25-cm-long vertical muscular tube that normally remains collapsed and that runs from the laryngopharynx (throat or hypopharynx) in the neck through the thorax (chest) to the stomach in the abdomen.

The stomach begins with the cardiac notch, which is between the intra-abdominal esophagus and the gastric fundus (the part of the stomach above a horizontal line drawn from the cardia). The body (corpus) of the stomach leads to the pyloric antrum which joins the duodenum at the pylorus, lying at the L1-L2 level to the right of the midline.

The duodenum has 4 parts: superior, descending, horizontal, and ascending:

  • The first (superior) part, or the bulb, is connected to the undersurface of the liver by the hepatoduodenal ligament.
  • The second (descending) part, or C loop, which has an upper and a lower (flexure), is composed of the transverse mesocolon and colon.
  • The third (horizontal) part, runs from right to left in front of the inferior vena cava and aorta, with superior mesenteric vessels (the vein on the right and the artery on the left) in front.
  • The fourth (ascending) part of the duodenum continues into the jejunum at the duodenojejunal flexure.

Consistency of Language
Before 2014, the 2013 esophagoscopy, EGD, and ERCP parent codes contained the terminology “diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure).” According to the CPT Editorial Panel replacing “with or without” in codes with “including, when performed” will standardize the terms and make the code descriptors more exact. This is an editorial change and does not change the way the codes are reported.

Moderate Sedation
It is important to understand that rigid transoral and flexible transnasal esophagoscopy DO NOT include moderate sedation. Rigid esophagoscopic procedures are usually done in an OR with deep sedation or general anesthesia. Transnasal esophagoscopy procedures are usually performed in offices, with topical anesthesia and the patient seated upright. Traditional flexible transoral EGDs include moderate sedation, therefore moderate sedation should not be coded in conjunction with CPT codes 43200-43232.

Updated Definition of Esophagoscopy
New to the Includes notes under endoscopic procedures esophagus, is the definition of what is included in a rigid and flexible transoral esophagoscopy:

Includes: Examination of upper esophageal sphincter (cricopharyngeus muscle) to/including the gastroesophageal junction and retroflexion examination of the proximal region of the stomach.

Type of Endoscopic Procedures
Prior to 2014, codes 43200-43232 encompassed both rigid and flexible transoral esophagoscopy. These two types of procedures have been given their own code families, which now reflect the different type of work and methods of sedation used for these procedures. CPT codes 43191 – 43196 describe transoral esophagoscopy using a rigid scope. So what is a rigid scope and what is it used for?

Rigid Endoscope

Rigid Endoscopes
Rigid endoscopes consist of a metal tube which contains a series of lenses, fiber optics or video chips for image transmission, as well as fiber optic bundles to deliver light. Rigid endoscopes offer the best image quality and resolution of all endoscope types. A working channel found in some scopes allows instruments to be passed through so surgeons can work in real-time.

Click here to view Table 1 – Rigid Esophagoscopy

Esophagoscopy (rigid) with Foreign Body Removal of Penny
The patient had a penny lodged in the proximal esophagus in the typical location.
An endotracheal tube was placed and securely taped to the left side of baby’s mouth, I positioned the patient with a prominent shoulder roll and neck hyperextension. A rigid esophagoscope was then inserted into the proximal esophagus, and the scope was gradually advanced with the lumen directly in frontal view. This was facilitated by the naso enteric feeding tube that was in place, which I followed carefully until the edge of the coin could be seen. At this location, there was quite a bit of surrounding mucosal inflammation, but the coin edge could be clearly seen and was secured with the coin grasping forceps. I then withdrew the scope, forceps, and the coin as one unit, and it was easily retrieved. The patient tolerated the procedure well. There were no intraoperative complications. There was only one single coin noted, and she was awakened and taken to the recovery room in good condition. CPT code 43194

Flexible Endoscope

Flexible Endoscopes
The flexible endoscope is more nimble than the rigid endoscope, allowing the provider to navigate the passages in the human body by controlling the directional movement of the scope that is entering the body. Since the lenses consist of flexible fibers, the image delivered is not as crisp and defined as with a rigid endoscope. The flexible endoscope is much more comfortable for the patient as well as being easier for the provider to use.

Flexible Transnasal Esophagoscopy
The Esophagoscopy subsection includes two new flexible transnasal esophagoscopy (TNE) codes (43197, 43198). TNE is performed to evaluate the esophagus from its inlet through the gastroesophageal junction. The nasal cavity (on one or both sides), nasopharynx, hypopharynx, and larynx are examined with the transnasal endoscope. The work involved in performing TNE differs from transoral esophagoscopy enough to warrant separate codes. Code 43197 describes diagnostic flexible TNE and includes collection of specimens by brushing or washing, when performed. Code 43198 describes flexible TNE with single or multiple biopsies.

Click here to view Table 2 – Transnasal Esophagoscopy

Esophagoscopy, Flexible, Transoral
Codes 43200-43232 have been revised to describe procedures using a flexible scope. Flexible esophagoscopy is typically performed using moderate sedation and the sedation is bundled into the flexible transoral esophagoscopy codes, as indicated by the moderate sedation symbol.

Deleted Codes
Three codes have been deleted in the esophagoscopy family:

  • Code 43219 – Stent or tube placement has been deleted; use new code 43212 to report Esophagoscopy, flexible, transoral; stent placement. The new code specifies the inclusion of pre- and post-dilation and guide wire passage when performed and includes moderate sedation as indicated by the moderate sedation symbol.
  • Code 43228 – Ablation of tumor has been deleted. A new code has been established for ablation of tumors with esophagoscopy (43229). The new code includes pre- and post-dilation and guide wire passage when performed. Moderate sedation is included, as indicated by the moderate sedation symbol.
  • Code 43234, which described a simple primary upper endoscopy, has been deleted. To report a diagnostic esophagogastroduodenoscopy, 43235 should be reported, or one of the three diagnostic esophagoscopy codes as appropriate

Click here to view Table 3 – Transoral, flexible, Esophagoscopy

New Codes
New 2014 CPT codes for the esophagoscopy family include stent, ablation, endoscopic mucosal resection, retrograde dilation, and dilation with balloon greater than 30 mm diameter. Stand-alone dilation codes (retrograde [43456]; >30 mm (for achalasia) [43458]) have been deleted, supporting the fact, that endoscopy is typically performed with esophageal dilation were performed.

Endoscopic Mucosal Resection
Code 43211 – Endoscopic Mucosal Resection (EMR) includes injection-assisted, cap-assisted, and ligation-assisted techniques. Code 43211 includes removal of tumor(s), polyp(s), or other lesion(s) by snare technique (43217); directed submucosal injection(s) (43201); and band ligation (43205), so these services are not separately reportable when performed on the same lesion during the same session. Biopsy (43202) performed on the same lesion as EMR is not separately reportable.

  • Injection-assisted EMR, also called ”saline-assisted ”EMR,” is used on large gastric lesions. The procedure starts with injection of a solution into the submucosal space under the lesion, creating a ”safety cushion.” The cushion lifts the lesion to facilitate its removal and minimizes mechanical or electrocautery damage to the deep layers of the esophagus.
  • Cap-assisted EMR also uses submucosal injection to lift the target lesion. Dedicated mucosectomy devices that use a cap affixed to the tip of the endoscope have been developed. These single-use devices come equipped with a specially designed crescent-shaped electrocautery snare that must be opened and positioned on the internal circumferential ridge at the tip of the cap.
  • In ligation-assisted EMR, a standard variceal band ligation device is positioned over the target lesion with or without prior submucosal injection. Suction is applied to retract the lesion into the banding device, and a band is deployed to capture the lesion. The banding device is then removed and a standard electrocautery snare is used to resect the lesion above.

Two new codes have been established: Code 43213 – Dilation of the esophagus with a balloon or dilator, retrograde approach; and Code 43214 for esophagoscopy with balloon dilation of 30 mm in diameter or larger (typically achalasia). These codes include fluoroscopic guidance when used, and moderation sedation, as indicated by the moderate sedation symbol.

Placement of Stent
Revised code descriptor language for placement of an endoscopic stent in the esophagus states “pre-and post-dilation and guide wire passage, when performed”. Code 43212, esophagoscopy with placement of stent is reported without a reduced services modifier 52, even if all three components (pre-dilation, post-dilation, and guide wire passage) are not performed during the same session. Separate reporting of pre-dilation, post-dilation or guide wire passage of the same lesion during the same session would not be appropriate.

Esophagoscopy, Flexible, Transnasal
In conclusion, remember to investigate these new code families thoroughly in the 2014 CPT code book. There are a lot of changes and the code descriptors as well as all of the includes notes must be read and understood before choosing the correct code to fit the procedure you are coding.

See page 2 for quiz questions.

Quiz Questions

1. What are the three parts of the nasopharynx?

A. The nasopharynx, the oropharynx and the laryngopharynx
B. The upper, middle and lower nasopharynx
C. The neck, thorax, and abdomen

2. What code cannot be coded with directed submucosal injections?

A. 43202
B. 43211
C. 43205
D. 43206

3. What is an injection assisted EMR?

A. An Injection that removes the lesion in the esophagus
B. A fine needle aspiration
C. An injection of anesthesia
D. An injection of solution to create a safety cushion to facilitate the removal of a lesion

A, B, D

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