Local Coverage Determination (LCD): Diagnostic and ...

Local Coverage Determination (LCD):
Diagnostic and Therapeutic
Esophagogastroduodenoscopy (L28856)

Contractor Information

Contractor Name
First Coast Service Options,
Inc.

LCD Information

Document Information

LCD ID
L28856

LCD Title Original Effective Date
Diagnostic and Therapeutic For services performed on or after 03/02/2009
Esophagogastroduodenoscopy

AMA CPT / ADA CDT / AHA NUBC Revision Effective Date

Copyright Statement For services performed on or after 01/01/2015

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the AMA is not recommending their use. The 10/01/2010

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medicine or dispense medical services. The Notice Period End Date
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not contained herein.

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CMS National Coverage Policy
Language quoted from CMS National Coverage Determinations (NCDs) and coverage
provisions in interpretive manuals are italicized throughout the Local Coverage Determination
(LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD
Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an
administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security
Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following
CMS sources:

CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations Manual,
Chapter , Section 100.3

Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity

Upper intestinal endoscopy is performed with a lighted, flexible, fiberoptic instrument passed
through the cricopharynx. The patient receives conscious sedation. A topical anesthetic is
sometimes applied to the posterior pharynx. Direct visualization of the entire esophagus,
stomach, and duodenum (to the junction of the second and third portions) can be accomplished
easily with modern instruments that are less than 12mm in diameter.
Esophagogastroduodenoscopy (EGD) is a technique utilized to examine, obtain samples, and in
some instances, to treat pathological conditions.

Diagnostic observations are made concerning focal benign or malignant lesions, diffuse mucosal
changes, luminal obstruction, motility, and extrinsic compression by contiguous structures. A
diagnostic EGD allows the examiner to visualize abnormalities detectable by the technique and

to photograph, biopsy, and/or remove lesions as appropriate.

The purpose of the therapeutic EGD is to manage hemorrhage; remove foreign bodies and
neoplastic growths; to relieve obstruction due to stricture, malignancy, or other causes through
dilatation or the placement of stents; and to assist in the placement of percutaneous gastrostomy
tubes.

EGD(s) will be considered medically reasonable and necessary under the following diagnostic
conditions:

· Patient has upper abdominal distress (e.g., gastroesophageal reflux disease) which persists
despite an appropriate trial of symptomatic therapy;

· Patient has upper abdominal distress associated with a short history of signs and symptoms
suggesting significant associated disease or illness (e.g., weight loss, anorexia, vomiting,
nonsteroidal anti-inflammatory drug [NSAID] intake, other gastric irritant intake);

· Patients over the age of 40 who have experienced a significant history of heartburn that returns
after a course of symptomatic therapy;

· Patients who have dysphagia or odynophagia;

· Patient has persistent, unexplained vomiting;

· Patient has upper gastrointestinal x-ray findings of:

- any lesion that requires biopsy for diagnosis; or-

- gastric ulcer suspicious of cancer; or

- evidence of stricture or obstruction;

· To assess acute injury after caustic agent ingestion;

· When anti-reflux surgery is contemplated; or

· Patient has gastrointestinal bleeding:

- in most actively bleeding patients; or

- for presumed chronic blood loss and iron deficiency anemia when investigation of large bowel
is negative.

EGD(s) will be considered medically reasonable and necessary for the following therapeutic
purposes:

· Treatment of bleeding lesions;

· Removal of foreign bodies;

· Sclerotherapy and/or band ligation for bleeding from esophageal or gastric varices;

· Dilatation of strictures in the upper intestinal tract;

· Removal of selected polypoid lesions;

· Placement of feeding tubes; or

· Palliative therapy of stenosing neoplasms (e.g., laser, stent placement).

Gastrointestinal bleeding may be treated with a variety of methods. Direct contact heater probes
and hemostatic injections into or around the bleeding vessels are both effective therapy for acute
bleeding.

Foreign body removal from the stomach or esophagus is usually successful with these flexible
instruments. The foreign bodies can be retrieved by either of two methods. The first method is to
capture the foreign body with a snare device/grasping forceps and pull the item out with the
endoscope. The second method is accomplished by piecemeal destruction and pushing the bolus
through the esophagus into the stomach.

Esophageal varices may be injected with a variety of sclerosing solutions. Eradication of varices
requires, on the average, five sclerotherapy sessions, with multiple injections given during each
session.

Dilatation of strictures may be accomplished with a balloon placed through the endoscope and
inflated using hydrostatic pressure. Bougies are rubber dilators available in various sizes up to
approximately 2.0cm. Plastic bougies and other dilating probes are usually passed over a guide
wire. This procedure involves placing the guide wire into the stomach through the endoscope.
The endoscope is then withdrawn leaving the guide wire in place. The dilating probes and plastic
bougies are then passed over the guide wire. After the largest dilator is used, the dilator and
guide wire are removed. Esophageal dilation is performed after a definitive diagnosis has been
established in patients exhibiting dysphagia. The goal in most cases is a lumenal diameter of 16-
17mm which allows passage of solid food. A series of dilators may be passed over the guide wire
to reach the goal of therapy.

Follow-up EGD(s) will be considered medically reasonable and necessary for the following
indications:

· Biopsy surveillance of patients with Barrett’s esophagus every 12 to 24 months. However, if
dysplasia is present, earlier surveillance intervals of from three to six months may be required;

· Follow-up of gastric ulcers to healing or satisfaction that they are benign;

· Follow-up and treatment of esophageal strictures requiring guidewire dilation;

· Follow-up of duodenal ulcer or other lesions of the upper gastrointestinal tract that have
resulted in serious consequences (e.g., hemorrhage);

· Follow-up of patients having a previous gastric polypectomy for adenoma; or

· Follow-up and treatment of patients with esophageal varices or bleeding lesions requiring
recurrent therapy (e.g., esophageal varices, gastric varices, angiodysplastic or watermelon
stomach lesions, radiation gastritis).

· Follow-up for removal of percutaneous gastrostomy tube (PEG)

Periodic EGD is NOT usually indicated in the following situations:

· Surveillance of healed, benign disease such as gastric or duodenal ulcer or benign esophageal
strictures; or

· Cancer surveillance in patients with pernicious anemia, treated achalasia, or prior gastric
resection.

EGD is generally contraindicated for patients with recent myocardial infarction.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to
report this service. Absence of a Bill Type does not guarantee that the policy does not apply to
that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by
Bill Type and the policy should be assumed to apply equally to all claims.

013x Hospital Outpatient
085x Critical Access Hospital

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes
typically used to report this service. In most instances Revenue Codes are purely advisory; unless
specified in the policy services reported under other Revenue Codes are equally subject to this
coverage determination. Complete absence of all Revenue Codes indicates that coverage is not
influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue
Codes.

0360 Operating Room Services - General Classification
0361 Operating Room Services - Minor Surgery
0750 Gastro-Intestinal (GI) Services - General Classification

CPT/HCPCS Codes

Group 1 Paragraph: 43233 Esophagogastroduodenoscopy, flexible, transoral; with dilation of
esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when
performed)

43253 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided
transmural injection of diagnostic or therapeutic substance(s) (eg, anesthetic, neurolytic agent) or
fiducial marker(s) (includes endoscopic ultrasound examination of the esophagus, stomach, and
either the duodenum or a surgically altered stomach where the jejunum is examined distal to the
anastomosis)

43254 Esophagogastroduodenoscopy, flexible, transoral; with endoscopic mucosal resection

43266 Esophagogastroduodenoscopy, flexible, transoral; with placement of endoscopic stent
(includes pre- and post-dilation and guide wire passage, when performed)

43270 Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or
other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)

Group 1 Codes:

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC,

43235 INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING,

WHEN PERFORMED (SEPARATE PROCEDURE)

43236 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH
DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH

43237 ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS,

STOMACH OR DUODENUM, AND ADJACENT STRUCTURES

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH

TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR

43238 TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), (INCLUDES

ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS,

STOMACH OR DUODENUM, AND ADJACENT STRUCTURES)

43239 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH
BIOPSY, SINGLE OR MULTIPLE

43241 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH
INSERTION OF INTRALUMINAL TUBE OR CATHETER

43243 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH
INJECTION SCLEROSIS OF ESOPHAGEAL/GASTRIC VARICES

43244 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH BAND
LIGATION OF ESOPHAGEAL/GASTRIC VARICES

43245 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH
DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG, BALLOON, BOUGIE)

43246 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH
DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE

43247 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH
REMOVAL OF FOREIGN BODY(S)

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH

43248 INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OF DILATOR(S)

THROUGH ESOPHAGUS OVER GUIDE WIRE

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH

43249 TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30

MM DIAMETER)

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH

43250 REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY

FORCEPS

ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH

43251 REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE

TECHNIQUE

43255 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH
CONTROL OF BLEEDING, ANY METHOD

ICD-9 Codes that Support Medical Necessity

Group 1 Paragraph: N/A

Group 1 Codes:

040.2 WHIPPLE'S DISEASE

112.84 CANDIDAL ESOPHAGITIS

150.0 - MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS - MALIGNANT

152.9 NEOPLASM OF SMALL INTESTINE UNSPECIFIED SITE

155.0 MALIGNANT NEOPLASM OF LIVER PRIMARY

156.0 - MALIGNANT NEOPLASM OF GALLBLADDER - MALIGNANT NEOPLASM

156.9 OF BILIARY TRACT PART UNSPECIFIED SITE

157.0 - MALIGNANT NEOPLASM OF HEAD OF PANCREAS - MALIGNANT

157.9 NEOPLASM OF PANCREAS PART UNSPECIFIED

159.8 MALIGNANT NEOPLASM OF OTHER SITES OF DIGESTIVE SYSTEM AND
INTRA-ABDOMINAL ORGANS

176.3 KAPOSI'S SARCOMA GASTROINTESTINAL SITES

197.4 SECONDARY MALIGNANT NEOPLASM OF SMALL INTESTINE INCLUDING
DUODENUM
197.6 SECONDARY MALIGNANT NEOPLASM OF RETROPERITONEUM AND
PERITONEUM
198.89 SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES
202.80 OTHER MALIGNANT LYMPHOMAS UNSPECIFIED SITE
211.0 - BENIGN NEOPLASM OF ESOPHAGUS - BENIGN NEOPLASM OF OTHER
211.9 AND UNSPECIFIED SITE IN THE DIGESTIVE SYSTEM
214.3 LIPOMA OF INTRA-ABDOMINAL ORGANS
214.9 LIPOMA UNSPECIFIED SITE
OTHER BENIGN NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE
215.9 SITE UNSPECIFIED
HEMANGIOMA OF INTRA-ABDOMINAL STRUCTURES
228.04 CARCINOMA IN SITU OF ESOPHAGUS - CARCINOMA IN SITU OF LIVER
230.1 - AND BILIARY SYSTEM
230.8 NEOPLASM OF UNCERTAIN BEHAVIOR OF STOMACH INTESTINES AND
RECTUM - NEOPLASM OF UNCERTAIN BEHAVIOR OF
235.2 - RETROPERITONEUM AND PERITONEUM
235.4 NEOPLASM OF UNSPECIFIED NATURE OF DIGESTIVE SYSTEM
ABNORMALITY OF SECRETION OF GASTRIN
239.0 NUTRITIONAL MARASMUS
251.5 MALNUTRITION OF MODERATE DEGREE - UNSPECIFIED PROTEIN-
261 CALORIE MALNUTRITION
263.0 - IRON DEFICIENCY ANEMIA SECONDARY TO BLOOD LOSS (CHRONIC) -
263.9 IRON DEFICIENCY ANEMIA UNSPECIFIED
280.0 - ACUTE POSTHEMORRHAGIC ANEMIA
280.9 CONVERSION DISORDER
285.1 GASTROINTESTINAL MALFUNCTION ARISING FROM MENTAL FACTORS
300.11 ANOREXIA NERVOSA
306.4 EATING DISORDER UNSPECIFIED
307.1 BULIMIA NERVOSA
307.50 PICA
307.51 RUMINATION DISORDER
307.52 PSYCHOGENIC VOMITING
307.53 DYSPHAGIA CEREBROVASCULAR DISEASE
307.54 RUPTURE OF ARTERY
438.82 HEREDITARY HEMORRHAGIC TELANGIECTASIA
447.2 ESOPHAGEAL VARICES WITH BLEEDING
448.0 ESOPHAGEAL VARICES WITHOUT BLEEDING
456.0 ESOPHAGEAL VARICES IN DISEASES CLASSIFIED ELSEWHERE WITH
456.1 BLEEDING - ESOPHAGEAL VARICES IN DISEASES CLASSIFIED
ELSEWHERE WITHOUT BLEEDING
456.20 - PNEUMONITIS DUE TO INHALATION OF FOOD OR VOMITUS
456.21

507.0

530.0 - ACHALASIA AND CARDIOSPASM - OTHER DISEASES OF ESOPHAGUS
530.89
ACUTE GASTRIC ULCER WITH HEMORRHAGE WITHOUT OBSTRUCTION -
531.00 - GASTRIC ULCER UNSPECIFIED AS ACUTE OR CHRONIC WITHOUT
531.91 HEMORRHAGE OR PERFORATION WITH OBSTRUCTION
ACUTE DUODENAL ULCER WITH HEMORRHAGE WITHOUT
532.00 - OBSTRUCTION - DUODENAL ULCER UNSPECIFIED AS ACUTE OR
532.91 CHRONIC WITHOUT HEMORRHAGE OR PERFORATION WITH
OBSTRUCTION
533.00 - ACUTE PEPTIC ULCER OF UNSPECIFIED SITE WITH HEMORRHAGE
533.91 WITHOUT OBSTRUCTION - PEPTIC ULCER OF UNSPECIFIED SITE
UNSPECIFIED AS ACUTE OR CHRONIC WITHOUT HEMORRHAGE OR
534.00 - PERFORATION WITH OBSTRUCTION
534.91 ACUTE GASTROJEJUNAL ULCER WITH HEMORRHAGE WITHOUT
OBSTRUCTION - GASTROJEJUNAL ULCER UNSPECIFIED AS ACUTE OR
535.00 - CHRONIC WITHOUT HEMORRHAGE OR PERFORATION WITH
535.71 OBSTRUCTION
536.1 ACUTE GASTRITIS (WITHOUT HEMORRHAGE) - EOSINOPHILIC
536.2 GASTRITIS, WITH HEMORRHAGE
536.3 ACUTE DILATATION OF STOMACH
536.40 - PERSISTENT VOMITING
536.49 GASTROPARESIS
GASTROSTOMY COMPLICATION UNSPECIFIED - OTHER GASTROSTOMY
536.8 COMPLICATIONS
DYSPEPSIA AND OTHER SPECIFIED DISORDERS OF FUNCTION OF
537.0 - STOMACH
537.89 ACQUIRED HYPERTROPHIC PYLORIC STENOSIS - OTHER SPECIFIED
538 DISORDERS OF STOMACH AND DUODENUM
551.3 GASTROINTESTINAL MUCOSITIS (ULCERATIVE)
552.3 - DIAPHRAGMATIC HERNIA WITH GANGRENE
552.8 DIAPHRAGMATIC HERNIA WITH OBSTRUCTION - HERNIA OF OTHER
553.3 SPECIFIED SITES WITH OBSTRUCTION
555.0 - DIAPHRAGMATIC HERNIA WITHOUT OBSTRUCTION OR GANGRENE
555.9 REGIONAL ENTERITIS OF SMALL INTESTINE - REGIONAL ENTERITIS OF
560.9 UNSPECIFIED SITE
562.01 UNSPECIFIED INTESTINAL OBSTRUCTION
562.02 DIVERTICULITIS OF SMALL INTESTINE (WITHOUT HEMORRHAGE)
562.03 DIVERTICULOSIS OF SMALL INTESTINE WITH HEMORRHAGE
569.62 DIVERTICULITIS OF SMALL INTESTINE WITH HEMORRHAGE
569.71 - MECHANICAL COMPLICATION OF COLOSTOMY AND ENTEROSTOMY
569.79
569.82 POUCHITIS - OTHER COMPLICATIONS OF INTESTINAL POUCH
569.87
ULCERATION OF INTESTINE
VOMITING OF FECAL MATTER

571.1 ACUTE ALCOHOLIC HEPATITIS
571.2 ALCOHOLIC CIRRHOSIS OF LIVER
571.3 ALCOHOLIC LIVER DAMAGE UNSPECIFIED
571.40 CHRONIC HEPATITIS UNSPECIFIED
571.41 CHRONIC PERSISTENT HEPATITIS
571.42 AUTOIMMUNE HEPATITIS
571.49 OTHER CHRONIC HEPATITIS
571.5 CIRRHOSIS OF LIVER WITHOUT ALCOHOL
571.6 BILIARY CIRRHOSIS
572.3 PORTAL HYPERTENSION
CALCULUS OF GALLBLADDER WITH ACUTE CHOLECYSTITIS WITHOUT
574.00 - OBSTRUCTION - CALCULUS OF GALLBLADDER WITH ACUTE
574.01 CHOLECYSTITIS WITH OBSTRUCTION
CALCULUS OF GALLBLADDER WITH OTHER CHOLECYSTITIS WITHOUT
574.10 - OBSTRUCTION - CALCULUS OF GALLBLADDER WITH OTHER
574.11 CHOLECYSTITIS WITH OBSTRUCTION
CALCULUS OF GALLBLADDER WITHOUT CHOLECYSTITIS WITHOUT
574.20 - OBSTRUCTION - CALCULUS OF GALLBLADDER WITHOUT
574.21 CHOLECYSTITIS WITH OBSTRUCTION
CALCULUS OF BILE DUCT WITH ACUTE CHOLECYSTITIS WITHOUT
574.30 - OBSTRUCTION - CALCULUS OF BILE DUCT WITH ACUTE CHOLECYSTITIS
574.31 WITH OBSTRUCTION
CALCULUS OF BILE DUCT WITH OTHER CHOLECYSTITIS WITHOUT
574.40 - OBSTRUCTION - CALCULUS OF BILE DUCT WITH OTHER CHOLECYSTITIS
574.41 WITH OBSTRUCTION
ACUTE CHOLECYSTITIS
575.0 FISTULA OF GALLBLADDER
575.5 POSTCHOLECYSTECTOMY SYNDROME
576.0 FISTULA OF BILE DUCT
576.4 ACUTE PANCREATITIS
577.0 CHRONIC PANCREATITIS
577.1 CYST AND PSEUDOCYST OF PANCREAS
577.2 HEMATEMESIS - HEMORRHAGE OF GASTROINTESTINAL TRACT
578.0 - UNSPECIFIED
578.9
579.0 - CELIAC DISEASE - UNSPECIFIED INTESTINAL MALABSORPTION
579.9
694.0 DERMATITIS HERPETIFORMIS
710.1 SYSTEMIC SCLEROSIS
747.61 GASTROINTESTINAL VESSEL ANOMALY
CONGENITAL TRACHEOESOPHAGEAL FISTULA ESOPHAGEAL ATRESIA
750.3 AND STENOSIS
OTHER SPECIFIED CONGENITAL ANOMALIES OF ESOPHAGUS
750.4 CONGENITAL HYPERTROPHIC PYLORIC STENOSIS
750.5

750.6 CONGENITAL HIATUS HERNIA
750.7 OTHER SPECIFIED CONGENITAL ANOMALIES OF STOMACH
783.0 ANOREXIA
783.21 -
783.3 LOSS OF WEIGHT - FEEDING DIFFICULTIES AND MISMANAGEMENT
784.42
784.43 DYSPHONIA
784.44 HYPERNASALITY
784.49 HYPONASALITY
784.52 OTHER VOICE AND RESONANCE DISORDERS
784.91 - FLUENCY DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE
784.99
786.2 POSTNASAL DRIP - OTHER SYMPTOMS INVOLVING HEAD AND NECK
786.50 -
786.59 COUGH
786.6
787.01 - UNSPECIFIED CHEST PAIN - OTHER CHEST PAIN
787.91
789.00 - SWELLING MASS OR LUMP IN CHEST
789.09
NAUSEA WITH VOMITING - DIARRHEA
789.30 -
789.39 ABDOMINAL PAIN UNSPECIFIED SITE - ABDOMINAL PAIN OTHER
SPECIFIED SITE
789.51 - ABDOMINAL OR PELVIC SWELLING MASS OR LUMP UNSPECIFIED SITE -
789.59 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP OTHER SPECIFIED
789.60 - SITE
789.69
790.5 MALIGNANT ASCITES - OTHER ASCITES
790.99
792.1 ABDOMINAL TENDERNESS UNSPECIFIED SITE - ABDOMINAL
TENDERNESS OTHER SPECIFIED SITE
793.4 OTHER NONSPECIFIC ABNORMAL SERUM ENZYME LEVELS
OTHER ABNORMAL FINDINGS ON EXAMINATION OF BLOOD
793.6 NONSPECIFIC ABNORMAL FINDINGS IN STOOL CONTENTS
NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER
799.4 EXAMINATION OF GASTROINTESTINAL TRACT
862.22 NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER
874.4 - EXAMINATION OF ABDOMINAL AREA, INCLUDING RETROPERITONEUM
874.5 CACHEXIA
935.1 - INJURY TO ESOPHAGUS WITHOUT OPEN WOUND INTO CAVITY
935.2 OPEN WOUND OF PHARYNX WITHOUT COMPLICATION - OPEN WOUND
936 OF PHARYNX COMPLICATED
938
947.0 FOREIGN BODY IN ESOPHAGUS - FOREIGN BODY IN STOMACH

FOREIGN BODY IN INTESTINE AND COLON
FOREIGN BODY IN DIGESTIVE SYSTEM UNSPECIFIED
BURN OF MOUTH AND PHARYNX

947.2 - BURN OF ESOPHAGUS - BURN OF GASTROINTESTINAL TRACT
947.3

959.01 - OTHER AND UNSPECIFIED INJURY TO HEAD - OTHER AND UNSPECIFIED

959.09 INJURY TO FACE AND NECK

983.2 - TOXIC EFFECT OF CAUSTIC ALKALIS - TOXIC EFFECT OF CAUSTIC

983.9 UNSPECIFIED

990 EFFECTS OF RADIATION UNSPECIFIED

996.82 COMPLICATIONS OF TRANSPLANTED LIVER

997.41 - RETAINED CHOLELITHIASIS FOLLOWING CHOLECYSTECTOMY - OTHER

997.49 DIGESTIVE SYSTEM COMPLICATIONS

E864.1* ACCIDENTAL POISONING BY ACIDS NOT ELSEWHERE CLASSIFIED

E864.2* ACCIDENTAL POISONING BY CAUSTIC ALKALIS NOT ELSEWHERE
CLASSIFIED

E864.3* ACCIDENTAL POISONING BY OTHER SPECIFIED CORROSIVES AND
CAUSTICS NOT ELSEWHERE CLASSIFIED

E864.4* ACCIDENTAL POISONING BY UNSPECIFIED CORROSIVES AND CAUSTICS
NOT ELSEWHERE CLASSIFIED

E961* ASSAULT BY CORROSIVE OR CAUSTIC SUBSTANCE EXCEPT POISONING

V10.00 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF UNSPECIFIED SITE
IN GASTROINTESTINAL TRACT

V10.03 - PERSONAL HISTORY OF MALIGNANT NEOPLASM OF ESOPHAGUS -

V10.04 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF STOMACH

V10.09 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER SITES IN
GASTROINTESTINAL TRACT

V12.71 PERSONAL HISTORY OF PEPTIC ULCER DISEASE

V12.72 PERSONAL HISTORY OF COLONIC POLYPS

V12.79 PERSONAL HISTORY OF OTHER SPECIFIED DIGESTIVE SYSTEM
DISEASES

V18.51 - FAMILY HISTORY, COLONIC POLYPS - FAMILY HISTORY, OTHER

V18.59 DIGESTIVE DISORDERS

V55.1 ATTENTION TO GASTROSTOMY

V58.61 LONG-TERM (CURRENT) USE OF ANTICOAGULANTS

V58.64 LONG-TERM (CURRENT) USE OF NONSTEROIDAL ANTI-
INFLAMMATORIES

V58.69 LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS

V69.1 INAPPROPRIATE DIET AND EATING HABITS

Group 1 Medical Necessity ICD-9 Codes Asterisk Explanation: ** According to the ICD-9-

CM book, diagnosis codes E864.1, E864.2, E864.3, E864.4 and E961 are secondary

diagnosis codes and should not be billed as the primary diagnosis.

ICD-9 Codes that DO NOT Support Medical Necessity

Paragraph: N/A

Codes:
XX000 Not Applicable

General Information

Associated Information
Documentation Requirements

The patient’s medical record (e.g., history and physical, office/progress notes, procedure report)
maintained by the ordering/referring physician must clearly indicate the reason for the EGD.
Also, the results of the EGD must be included in the patient’s medical record.

Utilization Requirements

It is expected that these services would be performed as indicated by current medical literature
and/or standards of practice. When services are performed in excess of established parameters,
they may be subject to review for medical necessity.

The CMS Manual System, Pub. 100-8, Program Integrity Manual, Chapter 13, Section 5.1
(http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf) outlines that "reasonable and
necessary" services are "ordered and/or furnished by qualified personnel." A qualified physician
for this service/procedure is defined as follows: A) Physician is properly enrolled in Medicare.
B) Training and expertise must have been acquired within the framework of an accredited
residency and/or fellowship program in the applicable specialty/subspecialty in the United States
or must reflect equivalent education, training, and expertise endorsed by an academic institution
in the United States and/or by the applicable specialty/subspecialty society in the United States.
This service will be considered medically reasonable and necessary only if performed by
providers of gastroenterology services, or other providers who have specialized training and
expertise in performing the procedure in question.
Sources of Information and Basis for Decision
American Society of Gastrointestinal Endoscopy. Appropriate use of gastrointestinal endoscopy.
Gastrointestinal Endoscopy, 52(6) 831-7.

Cappell, M.S., & Friedel, D. (2002). The role of esophagogastroduodenoscopy in the diagnosis
and management of upper gastrointestinal disorders. The Medical Clinics of North America
86(6) pg 1165-1216.

Revision History Information

Please note: Most Revision History entries effective on or before 01/24/2013 display with a

Revision History Number of "R1" at the bottom of this table. However, there may be LCDs

where these entries will display as a separate and distinct row.

Revision Revision

History History Revision History Explanation Reason(s) for Change

Date Number

Revision Number: 6

Publication: December 2014 Connection

LCR A2015-006

01/01/2015 R4 Explanation of revision: Annual 2015 HCPCS • Revisions Due To
Update. Under the “CPT/HCPCS Codes” CPT/HCPCS
Code Changes

section of the LCD, the following CPT codes

have descriptor changes: 43247 and 43250.

The effective date of this revision is based on

date of service.

01/01/2014 R3 Revisions Due To CPT/HCPCS Code Change • Revisions Due To
approved. CPT/HCPCS
Code Changes

Revision Number:5
Publication: January 2014 Connection
LCR A2014-010

01/01/2014 R2 Explanation of revision: Annual 2014 HCPCS • Revisions Due To
10/01/2011 R1 Update. Under the “CPT/HCPCS Codes” CPT/HCPCS
section of the LCD, the following new CPT Code Changes
codes and descriptors were added: 43233,
43253, 43254, 43266, and 43270. Under this • Automated Edits
same section, CPT code 43258 and descriptor to Enforce
were deleted, and CPT codes 43235 through Reasonable &
43239, 43241, 43243 through 43251, and Necessary
43255 had descriptor changes. Language was Requirements
updated under the “Indications and
Limitations of Coverage and/or Medical
Necessity” section of the LCD. The effective
date of this revision is based on date of
service.

Revision Number:4
Start Date of Comment Period:N/A
Start Date of Notice Period:10/01/2011
Revised Effective Date:10/01/2011

LCR A2011-078
September 2011 Connection

Explanation of Revision: Annual 2012 ICD-9-
CM Update. Deleted diagnosis code 997.4.
Added new diagnosis code range 997.41-
997.49. The effective date of this revision is
based on date of service.

Revision Number:3
Start Date of Comment Period:N/A
Start Date of Notice Period:07/01/2011
Revised Effective Date:06/14/2011

LCR A2011-057
June 2011 Connection

Explanation of Revision: Based on an outside
request to clarify our current training
statement outlined in this LCD, language
under the “Utilization Guidelines” section of
the LCD has been deleted and replaced with a
revised statement regarding the qualification
and training. Revisions will be effective based
on process date.

Revision Number:2
Start Date of Comment Period:N/A
Start Date of Notice Period:10/01/2010
Revised Effective Date: 10/01/2010

LCR A2010-050
September 2010 Bulletin

Explanation of Revisions: Annual 2011 ICD-
9-CM Update. Added diagnosis code 784.52
and descriptor. The effective date of this
revision is based on date of service.

Revision Number:1
Start Date of Comment Period:N/A
Start Date of Notice Period:10/01/2009
Revised Effective Date: 10/01/2009

LCR A2009-081
September 2009 Bulletin

Explanation of Revisions: Annual 2010 ICD-
9-CM Update. Added diagnosis codes 569.71-

569.79, 569.87, 784.42, 784.43, and 784.44.
Revised descriptors for diagnosis codes
784.49, 793.4 and 793.6. The effective date of
this revision is based on date of service.

Revision Number:Original
Start Date of Comment Period:N/A
Start Date of Notice Period:12/04/2008
Revised Effective Date:03/02/2009

LCR A2009-036PR/VI
December 2008 Bulletin

This LCD consolidates and replaces all
previous policies and publications on this
subject by the fiscal intermediary
predecessors of First Coast Service Options,
Inc. (COSVI and FCSO).

For Puerto Rico and the Virgin Islands
(00574) there was no previous LCD on this
subject. This document (L28856) is effective
on 03/02/2009.

08/08/2009 - This policy was updated by the
ICD-9 2009-2010 Annual Update.

8/1/2010 - The description for Bill Type Code
13 was changed
8/1/2010 - The description for Bill Type Code
85 was changed

8/1/2010 - The description for Revenue code
0360 was changed
8/1/2010 - The description for Revenue code
0361 was changed
8/1/2010 - The description for Revenue code
0750 was changed

09/06/2010 - This policy was updated by the
ICD-9 2010-2011 Annual Update.

11/21/2010 - For the following CPT/HCPCS
codes either the short description and/or the
long description was changed. Depending on
which description is used in this LCD, there

may not be any change in how the code
displays in the document:
43235 descriptor was changed in Group 1
43237 descriptor was changed in Group 1
43239 descriptor was changed in Group 1
43249 descriptor was changed in Group 1

08/27/2011 - This policy was updated by the
ICD-9 2011-2012 Annual Update.

Associated Documents

Attachments
Coding Guidelines
Related Local Coverage Documents
N/A
Related National Coverage Documents
N/A
Public Version(s)
Updated on 12/15/2014 with effective dates 01/01/2015 - N/A
Updated on 07/01/2014 with effective dates 01/01/2014 - 12/31/2014
Updated on 04/14/2014 with effective dates 01/01/2014 - N/A
Updated on 12/18/2013 with effective dates 01/01/2014 - N/A
Updated on 09/14/2011 with effective dates 10/01/2011 - 12/31/2013

FIRST COAST SERVICE OPTIONS
LOCAL COVERAGE DETERMINATION

CODING GUIDELINES

LCD Number

A43235

Contractor Name

First Coast Service Options, Inc.

Contractor Number

09101 –Florida
09201 – Puerto Rico/Virgin Islands

LCD Title

Diagnostic and Therapeutic Esophagogastroduodenoscopy

Coding Guidelines

Surgical endoscopy always includes diagnostic endoscopy according to the Current Procedural Terminology (CPT)
book. Medicare has special payment rules related to endoscopic procedures. The higher valued endoscopy includes
the value of the base endoscopy of the same family.

If the endoscopist has not traversed the pyloric channel into the duodenum, then an EGD has not been performed.
Report the actual service performed under the esophagoscopy/esophagogastroscopy procedural family (procedure
codes 43200-43234).

Some procedure codes listed in this policy represent the biopsy of one or more lesions or the removal of one or more
polyps or foreign bodies. Bill the applicable procedure code once, regardless of the number of biopsies, polyps or
foreign bodies obtained during the session.

Upper GI bleeding can be treated by several endoscopic techniques. All methods used during the session to control
bleeding are reported using a single procedure code (43255).

Other Comments

Terms defined:

Odynophagia- pain when swallowing.

Dysphagia- inability or difficulty swallowing.

Achalasia- failure of the sphincter to relax. Failure of the cardiac sphincter to relax results in difficulty passing food
to the stomach.

Revision History

Date Revision
Original
02/16/2009 – Florida
03/02/2009 – Puerto Rico/Virgin Islands

Document formatted: 11/11/2008 (JM/st)