AHA Coding Clinic® for HCPCS - 2024 Issue 2; Ask the Editor

EGD with forceps biopsies and EUS with FNA biopsies of separate lesion

The patient presented for an esophagogastroduodenoscopy (EGD) with endoscopic ultrasound (EUS). The flexible endoscope was passed under direct vision through the mouth and advanced to the second part of the duodenum. LA Grade B esophagitis was found, and biopsies of the esophagus were taken with cold biopsy forceps for histopathology. In the gastric body, mild inflammation, congestion, and erythema were found; biopsies of the stomach were taken with cold biopsy forceps for histopathology. The duodenal bulb and second portion of the duodenum were normal. The EUS was completed without difficulty examining the esophagus, stomach, and the duodenum. Endosonographic findings of the pancreas and bile ducts were normal. However, three enlarged lymph nodes were visualized in the porta hepatic region. Fine-needle aspirations (FNA) of the lymph nodes were performed for cytology with a 25-gauge needle. Is it appropriate to assign separate CPT codes for the endosonographic FNA biopsies of the lymph nodes and the EGD with cold forceps biopsies of the stomach and esophagus since the FNA biopsies and the forceps biopsies were performed on separate sites/body parts? ...

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