Abstract from Documentation: Refer to Bladder, Tumor in the Alphabetic Index. Based on the operative technique, what choice is applicable?

An upper gastrointestinal endoscopy is a procedure that uses a lighted instrument (scope) to visualize the esophagus, stomach, and duodenum. The CPT code description also includes the possibility of visualizing the jejunum; however, this is not typical.

Did the physician just visualize the structures or perform another procedure during the endoscopy?
Answer: There were 3 polyps removed from the stomach, using a snare technique.


CPT Index Term (there may be several entries in the index leading to the correct range)
43247, 43250–43251 Endoscopy, Gastrointestinal, Upper, Removal

CPT Code Assignment:
43251 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of tumor(s), polyps(s), or other lesion(s), by snare technique
?

The choices are Excision, Fulguration, and Resection.

Underline the supportive documentation.
The surgeon used a loop electrode (fulguration method with use of electric current) to remove the bladder tumor. Narrow the choices to 52234–52240. The decision is based on the size of the tumor.

CPT Code Assignment:

52235 Cystourethroscopy, with fulguration; medium bladder tumor(s) (2.0 to 5.0 cm)