June 30, 2009

ACR Radiology Coding Source™ May-June 2009

Coding for an Upper GI Series and Esophagram

An upper gastrointestinal (GI) series (CPT codes 74240-74249) involves the evaluation of the upper GI tract, including the esophagus, stomach, and duodenum as stated in the ACR standard for these procedures. Typically, this includes fluoroscopic and spot film evaluation of the esophagus. Because routine evaluation of the esophagus is inherent in a GI series, it is not appropriate to report 74240, Radiologic examination, gastrointestinal tract, upper; with or without delayed films, without KUB, and 74220, Radiologic examination; esophagus. In this situation, only the upper GI code should be submitted, and not a separate esophagram code. National Correct Coding Initiative (NCCI) edits limit payment to an upper GI series (74240) when 74240 and a radiologic examination of the esophagus (74220) are reported on the same day by the same physician. 

In rare circumstances, a patient's symptoms may require a more extensive evaluation of the esophagus, particularly of the cervical esophagus, requiring multiple patient positions, video or cine recording, and dual contrast hypopharyngogram images. In these cases, the reporting of both an upper GI code (74240-74249) and a "radiologic examination, pharynx and/or cervical esophagus" code (74210) may be indicated when both procedures are performed in the same session or on the same day. NCCI edits in this instance allow the separate reporting of the cervical esophagram when a modifier is used to designate that a separate and distinct study was performed (e.g., 74210-59). Appropriate documentation is necessary to describe the reason why two exams were indicated and performed. 

In other unusual situations, an examination of swallowing function, pharyngeal and/or esophageal motility may also be performed (code 74230) in addition to an upper GI series. This study provides important information about a patient's ability to ingest materials of varying consistencies from liquid to solid that is not inherent in an upper GI examination. When the swallowing function (code 74230) is performed concurrent with an upper GI, it is reported separately. This code is not included in the CCI edits; therefore, the addition of the 59 modifier is not necessary. 

There are also many clinical situations where an esophagram (code 74220) by itself (without an upper GI examination) is an appropriate diagnostic imaging procedure. According to the ACR standard, an esophagram is usually indicated in patients with suspected or known motility disorders, esophagitis, strictures, varices, neoplasms, esophageal obstruction and postoperative assessment. Pertinent history and symptoms serving as indications for an esophagram include chest pain of suspected noncardiac origin, symptomatic or suspected gastroesophageal reflux, dysphagia, and odynophagia. 

Please note that there are also CCI edits in place for the performance of a swallowing function study with an esophagram or pharynx and/or cervical esophagus. Be sure to check the complete listing of the most current NCCI edits on the Centers for Medicare & Medicaid Services Web site.  

Also reference the AMA/ACR Clinical Examples in Radiology, Summer 2006, pp. 4-5, for more information on the coding of an esophagram.