In an EGD, three biopsies performed during the same scope count as one, single service when it comes to billing. It is easy to overlook this, particularly when the details of the operative report list multiple specimens, containers, and findings.
The CPT code for this service describes a flexible, transoral esophagogastroduodenoscopy (EGD) with biopsy. To assign this code, it is important to confirm biopsy(ies) have been performed, evaluate the extent of the service provided, and compare the encoded service to the clinical justification provided.
The goal for gastroenterology practices is to report all the services rendered, avoid reporting the same service twice, and include all services which are separately reportable.
43239 CPT Code Description and Included Services
The code describes a procedure where a physician performs an examination of the upper gastrointestinal tract using a flexible endoscope, and if necessary, obtains a biopsy. Endoscopic examinations of the upper GI tract include the esophagus, stomach and duodenum. This code incorporates both the endoscopic examination and biopsy. Evaluating biopsy specimens is considered a separate service and is assigned a different code.
One session, one code for biopsy procedure
When reporting multiple biopsies performed during the same EGD, assign one code, 43239.
Although a physician may collect biopsy samples from the gastric antrum, body, and duodenum during a single endoscopic exam, it would not warrant reporting three biopsy codes.
The types of tissue samples collected are often described on specimen containers. This does not dictate the number of biopsy procedures that can be billed.
Brushings and washings differ from biopsies
Just because a specimen was collected during an EGD, does not mean it was a biopsy.
An esophagogastroduodenoscopy (EGD) can be diagnostic if specimens are collected by brushings or washings. If no biopsy is performed and no other diagnostic code is assigned, code 43235 is appropriate. Code 43239 is only appropriate if the documentation clearly supports brushings or washings performed under endoscopic control.
Clinical Indications: Start With the Record, Not the Symptoms Alone
An EGD with biopsy may be performed to investigate symptoms, evaluate an abnormal finding, or assess an established condition.
Examples include:
Dysphagia or persistent upper abdominal symptoms.
Evaluation of unexplained iron deficiency anemia.
Gastric tissue sampling for suspected inflammation or infection.
Duodenal biopsies during a celiac disease evaluation.
Barrett’s esophagus surveillance.
Assessment of an ulcer or suspicious mucosal abnormality.
These are possible clinical circumstances, not automatic coverage criteria. The indication must be supported by the patient’s record and applicable payer policy.
An EGD order does not denote a biopsy was collected. Code based on the procedural description from the completed EGD.
Normal mucosa does not always mean a biopsy was not collected. A biopsy may be warranted in the absence of an abnormal mucosal lesion. In such cases, the final determination for coding is based upon the description of the procedure and the specimens.
CPT 43239 Versus Other Upper Endoscopy Codes
The 43239 CPT code description refers to tissue sampling. It should not be treated as a catch-all code for every intervention performed during an upper endoscopy.
| CPT code | Service distinction |
|---|---|
|
43235 |
Diagnostic EGD, including brushings or washings when performed |
|
43239 |
EGD with biopsy, single or multiple |
|
43247 |
EGD with foreign-body removal |
|
43250 |
EGD with lesion removal using hot biopsy forceps |
|
43251 |
EGD with lesion removal using a snare |
|
43249 |
EGD with transendoscopic esophageal balloon dilation, less than 30 mm |
|
43254 |
EGD with endoscopic mucosal resection |
|
43255 |
EGD with control of bleeding |
These abbreviated descriptions help distinguish the procedures. Complete code instructions and applicable edits still govern reporting.
Biopsy vs. Lesion Removal
Removing a lesion and obtaining a biopsy to be sent for pathologic examination should not be considered as the same thing.
Depending on the instrumentation and the stated purpose, a biopsy of a lesion may have been obtained.
Note: snare removal of a lesion should not be considered as a routine forceps biopsy. Similarly, if a pathologic specimen is obtained by EUS-guided needle sampling, an appropriate coding review should be performed.
Same-Session Services: Separate Work or Included Work?
An EGD can involve more than one intervention. That makes the relationship between services just as important as the individual code descriptions.
Diagnostic inspection is included
Do not combine the codes 43235 and 43239 for the diagnostic examination performed during the same EGD with biopsy.
In the more comprehensive endoscopic procedure, the diagnostic evaluation is considered part of the procedure and does not create a separate diagnostic service.
Sampling and Excising the Same Lesion
It is generally considered that the biopsy of a lesion is included in the procedure code for the subsequent excision.
A biopsy of a different lesion may allow for additional reporting. How ever, there is no absolute certainty for either deleting all biopsy procedure codes or adding modifier 59 in every case.
The biopsy and excision of a lesion should be reported to adequately represent the services rendered.
Bleeding Caused by Procedure
In most cases, controlling post-biopsy bleeding occurs as part of the biopsy procedure, and a code for the biopsy is typically all that is reported. An additional code for controlling the bleeding would not be supported, except in unusual circumstances.
Control of a remote, unrelated bleeding lesion would need to be reviewed separately. Supporting documentation would need to differentiate control of the bleeding from expected procedure-related bleeding.
Documentation That Makes the Claim Defensible
A useful operative report connects the clinical indication with the examination and tissue collection.
It should include:
The reason for the procedure and relevant history.
Endoscope route and extent reached.
Findings in the areas examined.
Biopsy location or locations.
Sampling technique.
Specimen identification and disposition.
Additional interventions and their locations.
Complications or limitations.
Follow-up plan and clinician authentication.
“EGD with biopsy” identifies the general service, but it leaves important details unanswered.
Example of Illustrative Documentation
EGD was performed for epigastric pain. It was extended to the second part of the duodenum. Erythema was seen in the gastric antrum. Biopsies from the antrum and the body were taken using the cold forceps method and sent in labeled biopsy containers.
This shows the biopsy technique and locations. It should not be used to substitute a complete report.
Maintain uniformity of procedure and pathology records
Pathologic information supplements and clarifies the record. It does not substitute the description of the procedure by the performing clinician.
If there is a discrepancy between the location of the biopsy documented on the procedure record and the specimen record, resolve the discrepancy prior to billing. Do not attempt to interpret specimen labels to describe the procedure performed. Not all laboratory results correlate with the endoscopist’s impression of pathology.
ICD-10 Linkage Without Guesswork
The diagnosis should reflect the documented clinical circumstances. It should never be selected merely because it appears on a payer’s coverage list.
Potential examples include:
| ICD-10-CM code | Condition or symptom |
|---|---|
|
R10.13 |
Epigastric pain |
|
R13.10 |
Dysphagia, unspecified |
|
K21.9 |
Gastroesophageal reflux disease without esophagitis |
|
K22.70 |
Barrett’s esophagus without dysplasia |
|
D50.0 |
Iron deficiency anemia secondary to chronic blood loss |
|
K90.0 |
Celiac disease |
These examples are not a universal list of approved diagnoses. Coverage varies, and each code requires support in the patient’s record.
Unconfirmed conditions can’t be coded as diagnoses
Codes for suspected conditions in outpatient visits cannot be assigned if a biopsy has only been ordered.
A biopsy of the duodenum to evaluate possibility of celiac disease does not support coding of celiac disease. Follow your facility’s policies for outpatient diagnostic codes and assume uncertainty unless certainty is specifically documented.
When a final report is available to the coder, the rules for confirmed diagnoses apply.
Additional information will be coded if and only if the information is adequately documented in the record. A statement in a report saying that the diagnosis in question is not supported will not allow the coder to assign that alternative diagnosis, particularly if the documentation does not also support that alternative.
Modifier Selection: Match the Circumstance
Modifiers explain particular circumstances. They cannot turn included work into a separate service or make an unsupported procedure medically necessary.
Distinct and multiple procedures
Modifier 59 or an X modifier may apply when the relevant edit permits separate reporting and when there is documentation of a qualifying distinct service.
In the absence of other mitigating circumstances, reporting different diagnoses will not allow for separate payment. Consider the context of the procedure including the location and whether the other procedures were performed during the same encounter.
Modifier 51 will not replace a required NCCI edit and will identify procedures that should be reported together, in accordance with payer’s rules and guidelines.
Reduced, discontinued, and repeat services
| Modifier | Circumstance requiring review |
|---|---|
|
22 |
Substantially increased procedural work, supported by a clear explanation |
|
52 |
Reduced services, assessed against procedure-specific instructions |
|
53 |
A started professional service discontinued because of extenuating circumstances or patient safety concerns |
|
73 / 74 |
Eligible outpatient hospital or ASC discontinued-procedure reporting |
|
76 / 77 |
A genuine repeat procedure, with the practitioner relationship and clinical reason documented |
Circumstances require careful analysis when a procedure has been partially performed. Often, there are disparate explanations for pausing a procedure from the claims processed by the professional and facility.
Append 26 or TC to unitize EGD procedures into professional and technical components is not allowed. Attending to other service components (pathology for instance) would require a different approach.
Unclear about Coding for EGD or Modifiers?
We can help with difficult cases, especially when biopsy details and same-session procedures are documented and coding is unclear. Our team will review your documentation and the use of modifiers prior to medical billing and coding to help resolve any issues.
Reimbursement, Pathology, and Sedation
Reimbursement for a CPT 43239 claim can vary based on the payer, contract terms, geographic location, place of service, and any other procedures reported on the same date.
When multiple endoscopic procedures are performed during one encounter, payment is not always equal to the full reimbursement for each individual code. Payer rules and multiple-procedure policies may affect the final allowed amount.
Pathology billing is also handled separately from the endoscopic procedure. The pathology service is billed according to the specimen evaluation and level of work performed by the laboratory or pathologist, while sedation and the endoscopy claim must follow their own documentation and payer requirements.
Biopsy collection and pathology are different services
The endoscopist removes the tissue and sends it to the pathology lab for analysis.
The pathology coder needs to ensure the pathology documentation and coding describe the specimens received, the work done, the billing entity and the reason for the service performed.
It is the pathology coder’s responsibility to analyze each situation and make the appropriate conclusions. Assuming that multiple pathology jars equal multiple pathology codes is incorrect. Likewise assuming that one tissue specimen equals multiple pathology units is incorrect.
Sedation Deserves Independent Evaluation
Moderate sedation should not be added to each EGD claim and automatically assumed.
Assess the provider’s role, the age of the patient, the documented time, and payer’s polices. Medicare allows payment for a qualifying GI endoscopy with sedation via G0500. When sedation is furnished by more than one source, the other components of the procedure should be billed and sedation should not be reported.
A Practical Pre-Bill Check
Before releasing a claim, compare the 43239 CPT code description with the completed operative report.
Confirm tissue sampling. A biopsy was performed, not merely scheduled.
Check units. Multiple specimens have not created duplicate 43239 lines.
Verify technique. Biopsy, snare removal, dilation, and other interventions are correctly distinguished.
Review diagnosis linkage. Symptoms and conditions are supported by the record.
Resolve edits. Any additional code or modifier has a documented basis.
Check payer requirements. Coverage, authorization, and submission rules apply to the actual plan and service date.
Reconcile discrepancies. Procedure details, specimens, and charges tell a consistent story.
Claim-scrubbing software can flag duplicate units or missing fields. It cannot reliably resolve an unclear relationship between two lesions without clinical documentation and coding review.
Denial Resolution Without Repeating the Same Error
The payer provides a rationale for the denial along with remark codes. Those codes help explain the reason denial and assist in understanding what was submitted on the claim.
Actual errors on the claim, e.g. missing information, should be corrected and submitted as a new claim. Appeals should be submitted if the payer agrees with the coding, but denies payment.
Comments should identify the reason for the dispute and include supporting records. The payer should be contacted and the dispute resolved before the appeal window closes. Repeatedly filing an appeal without communicating the reason for the dispute does not enforce urgency and may delay the resolution of the dispute.
Frequently Asked Questions
Can multiple biopsy sites increase 43239 units?
No. The code includes single or multiple biopsies performed during the same EGD session. Additional sites or specimens do not create additional procedure units.
Can 43235 and 43239 be billed for the same EGD?
Not for the diagnostic inspection and biopsy performed as part of one procedure. The diagnostic examination is included in the biopsy service.
Is a visible abnormality required for 43239?
No. A medically necessary biopsy may be obtained even when the mucosa appears normal. The record must document the sampling and clinical reason.
Can 43239 be reported with snare removal?
Potentially, when the biopsy represents separately reportable work and the applicable instructions and edits permit it. Sampling and removing the same lesion generally do not support separate biopsy reporting.
Should a negative pathology result change the procedure code?
A negative result does not undo a biopsy that was performed. Procedure coding reflects the documented service, while diagnosis coding follows the supported findings and applicable guidelines.
Is modifier 59 required whenever another procedure occurs?
No. The modifier requires a qualifying distinct service and an applicable coding basis. A second procedure or different diagnosis alone is not enough.
