For GI clinics and ASCs, accurate coding and documentation are critical to protecting reimbursement, reducing denials and withstanding payer audits.
The list below highlights 20 high-volume procedures across upper endoscopy, colonoscopy and GI physiology testing, along with key documentation elements practices should consistently capture, according to a recent blog post from medical billing company MBW RCM.
1. Diagnostic EGD (CPT code 43235)
Used for GERD evaluation, upper abdominal pain, iron deficiency anemia workup, dysphagia screening, and chronic nausea or vomiting. Documentation should include the extent of the examination, key findings and photo documentation of anatomical landmarks.
2. EGD with biopsy (CPT code 43239)
Common indications include Helicobacter pylori testing, celiac disease, Barrett’s surveillance and eosinophilic esophagitis. Documentation should include biopsy location, number of specimens and clinical indication. Unclear indications may trigger payer review.
3. EGD with snare lesion removal (CPT code 43251)
Used for gastric polyps, duodenal adenomas and small mucosal lesions. Documentation should include lesion size, location, resection completeness and retrieval confirmation.
4. EGD with endoscopic mucosal resection (CPT code 43254)
Used for early mucosal neoplasia and dysplasia. Documentation should include lesion size, location, resection technique and margin status if known.
5. EGD with stent placement (CPT code 43266)
Common indications include malignant obstruction, refractory strictures and leak or fistula management. Documentation should include stricture location and length, stent type and size and placement confirmation. Prior authorization is often required.
6. Diagnostic colonoscopy (CPT code 45378)
Common indications include colorectal cancer screening, GI bleeding, chronic diarrhea, anemia and IBD evaluation. Documentation should include cecal intubation confirmation, bowel prep quality and screening versus diagnostic indication.
7. Colonoscopy with biopsy (CPT code 45380)
Used when abnormal mucosa is identified including suspected colitis and IBD. Documentation should include biopsy location, number of specimens and linked indication. Modifier misuse is a common denial risk.
8. Colonoscopy with snare polypectomy (CPT code 45385)
Used for polyp removal via hot or cold snare. Documentation should include polyp size, morphology, colon segment location and retrieval confirmation.
9. Colonoscopy with endoscopic mucosal resection (CPT code 45390)
Used for large sessile or laterally spreading lesions. Documentation should include lesion size, injection agent, resection method and hemostasis if performed.
10. Colonoscopy with submucosal injection (CPT code 45381)
Used for lesion lift prior to resection or tattoo placement. Documentation should include injection purpose, location and agent used if applicable.
11. Capsule endoscopy, small bowel (CPT code 91110)
Common indications include obscure GI bleeding, Crohn’s disease and unexplained iron deficiency anemia. Documentation should include indication and key findings.
12. Capsule endoscopy, colon (CPT code 91113)
Used when traditional colonoscopy is incomplete or contraindicated. Documentation should include indication and adequacy of visualization.
13. Liver elastography (CPT code 91200)
Used for assessment of liver fibrosis and steatosis in nonalcoholic fatty liver disease, nonalcoholic steatohepatitis and viral hepatitis. Documentation should include clinical indication and fibrosis assessment results.
14. Hydrogen or methane breath test (CPT code 91065)
Used for small intestinal bacterial overgrowth, lactose intolerance and fructose malabsorption evaluation. Documentation should include substrate used and interpretation of results.
15. Esophageal motility study (CPT code 91010)
Used for dysphagia and suspected motility disorders. Documentation should include indication and pressure findings.
16. Esophageal pH or impedance testing (CPT code 91035)
Used for refractory GERD and non-acid reflux evaluation. Documentation should include acid exposure data and symptom correlation.
17. Anorectal manometry (CPT code 91122)
Used for chronic constipation, fecal incontinence and dyssynergic defecation. Documentation should include resting and squeeze pressures and functional findings.
18. Rectal sensory testing (CPT code 91120)
Often performed with anorectal manometry to assess rectal sensation. Documentation should include sensory thresholds and interpretation.
19. Esophageal function study with electrode (CPT code 91037)
Used for detailed evaluation of esophageal motility disorders. Documentation should include indication and motility findings.
20. Extended esophageal function testing (CPT code 91038)
Used for complex cases requiring prolonged motility monitoring. Documentation should include the reason for extended monitoring and key findings.
