tci General Surgery Coding Alert - 2016 Issue 11

You Be the Coder: Document EMR Steps

Question: When our surgeon performs an EMR, we find that payment for the claims is hit or miss. Is there some specific documentation needed to use the EMR codes as opposed to another endoscopy code? California Subscriber Answer: Yes, there are specific steps that the op note must document for you to appropriately code an Endoscopic Mucosal Resection (EMR) procedure. When you have appropriate documentation, you should choose one of the following EMR codes based on the type of scope and portion of the digestive tract involved in the procedure: 43211 — Esophagoscopy, flexible, transoral; with endoscopic mucosal resection...

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