ASGE members may submit coding inquiries electronically to codingquestions@asge.org. When submitting a question, please allow at least three business days for a response. When submitting inquiries, please include the ASGE member’s name and ID number. Only questions will be accepted and not reports. Below are two questions that could be beneficial to your practice.
Question #1
A Bravo, CPT code 91035, was performed and did not show active reflux, therefore, the diagnosis attached was dysphonia, which the insurance is denying. What other diagnosis could be used? The EGD also had the same diagnosis of dysphonia which is likely contributing to the denial. I did try to find a local coverage determination (LCD) for 91035 Bravo with no such luck. The patient has no other symptoms, and there were no findings in either the Bravo or the EGD.
Answer
This is where preauthorization and verification of eligibility are essential at the time of scheduling. If these were not "approved indications," the patient should have been informed and an advance beneficiary notice of noncoverage (ABN)/waiver should have been signed. Your providers also need to be aware of coverage indications. For example, most payers have policies on esophageal pH monitoring as well as EGDs (upper GI endoscopy), and dysphonia is not on the list. Make sure that your providers are aware that all upper GI symptoms should be documented and put in the indications field for diagnostic studies and endoscopy procedures to support medical necessity requirements.
Question #2
If a provider sees an ulcer in the stomach during an EGD and biopsies it, but the path report comes back with a diagnosis of inflammation and not ulceration, would I still code it as an ulcer, or would I use another condition of the stomach?
Answer
Pathology doesn't necessarily confirm what the physician actually saw with the naked eye, so in the case of an ulcer, it is recommended to use the ulcer code based on what your doctor saw and to contact your doctor for confirmation.