Based on a review of the trickier revisions in the 2003 edition of Current Procedural Terminology, here's how to document your GI endoscopy, orthopedics and GYN surgery cases.

Gastrointestinal endoscopy
The CPT codes for GI endoscopy have been overhauled, with several additions pertaining to procedures with injection or dilation, including:

43201 Esophagoscopy, rigid or flexible; with directed submucosal injection(s), any substance.

43236 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed submucosal injection(s), any substance.

45335 Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance.

45340 Sigmoidoscopy, flexible; with dilation by balloon, 1 or more strictures.

45381 Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance.

45386 Colonoscopy, flexible, proximal to splenic flexure; with dilation by balloon, 1 or more strictures.

Be sure that your medical records show each anatomical site examined with the endoscope (such as the esophagus, stomach, descending colon, transverse colon and small intestine). This could be the difference between submitting for code 43201 or 43236. Also document:

• Whether the surgeon performs an endoscopic ultrasound exam.
• Whether the surgeon places a transendoscopic device (including catheter), intraluminal tube or stent (including predilation).
• The type of surgical procedure performed on each lesion (polyp, tumor, cyst or stricture) present. If biopsy is performed, indicate the type of biopsy for each lesion: partial or total removal with cold biopsy forceps, hot biopsy forceps removal, aspiration with a transendoscopic ultrasound-guided intramural fine needle or transendoscopic ultrasound-guided transmural fine needle.

Orthopedics
The new CPT code for rotator cuff repair is 29827 (Arthroscopy, shoulder, surgical; with rotator cuff repair). Make sure the surgeon documents:

• Whether the rotator cuff tear is acute or chronic.
• Whether the patient suffered a complete rotator cuff avulsion.
• The specific muscles and tendons repaired (the CPT coding guidelines state that the repair of a complete rotator cuff avulsion refers to the repair of all three major muscles/tendons of the shoulder cuff).
• Whether the surgeon performed acromioplasty.
• Whether the surgeon repaired the tear with open surgery or arthroscopy.

The new CPT code for knee surgery is 29873 (Arthroscopy, knee, surgical; with lateral release). Existing CPT code 27425 has been revised to apply to an open lateral retinacular release. Document the anatomic location of the release (left and/or right knee) and the surgical technique used for the release (open or arthroscopic).

The new CPT code for ankle arthrodesis is 29899, which pertains to "arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with ankle arthrodesis." The new code supplements existing codes 27870 and 27871. Indicate the laterality of the procedure (right or left ankle), the location(s) of the arthrodesis (tibiofibular joint, tibiotalar joint, fibulotalar joint or other) and whether the procedure was open or endoscopic surgery.

GYN surgery
Two notable overhauls affect colposcopy and fistula repairs. There are new codes for colposcopies and the existing codes (57452, 57454 and 57460) were revised. The new codes are:

56820 Colposcopy of the vulva.

56821 Colposcopy of the vulva; with biopsy(s).

57420 Colposcopy of the entire vagina, with cervix if present.

57455 Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix.

57456 Colposcopy of the cervix including upper/adjacent vagina; with endocervical curettage.

57461 Colposcopy of the cervix including upper/adjacent vagina; with loop electrode conization of the cervix.

Document the anatomic site(s) examined (vulva, cervix, upper/adjacent vagina) and the type of procedure(s) performed.

If your GYN surgeon performs an anal fistula repair, new code 46706 pertains to repairing the fistula with fibrin glue and should not be confused with existing codes 46270, 46275, 46280, 46285 and 46288. Document the type (single or multiple repair) and level (subcutaneous or submuscular) of fistula, and the the type of repair.

Contact Lolita M. Jones at [email protected].