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Question 1 of 7
1. Question
What is the most precise interpretation of Coding for gastrointestinal cancers and their staging for Certified Gastroenterology Coder (CGIC)? A 64-year-old patient undergoes an esophagectomy following a diagnosis of a lesion in the distal esophagus. The final pathology report identifies a moderately differentiated adenocarcinoma. The pathologist notes that the tumor has deeply invaded the muscularis propria but has not penetrated the esophageal adventitia. A total of 18 regional lymph nodes were harvested, all of which were negative for malignancy. Preoperative PET/CT scans showed no evidence of distant metastatic disease. Which of the following represents the most accurate TNM staging and ICD-10-CM coding assignment for this case?
Correct
Correct: In the TNM staging system for esophageal cancer, a tumor that invades the muscularis propria is classified as T2. Since 18 lymph nodes were examined and found negative, the nodal status is N0. The absence of distant metastasis is recorded as M0. For ICD-10-CM, the distal esophagus is synonymous with the lower third, which is specifically reported using code C15.5.
Incorrect: The classification of T1b is incorrect because it refers to invasion of the submucosa, not the muscularis propria; additionally, C15.4 refers to the middle third of the esophagus. T3 is incorrect because it requires invasion into the adventitia, and N1 is incorrect as it indicates regional lymph node metastasis, which was not present. Tis and D00.1 are incorrect because they refer to carcinoma in situ, which is limited to the epithelium and has not invaded the deeper layers like the muscularis propria.
Takeaway: Accurate coding for esophageal cancer requires correlating the pathological depth of invasion with the correct T stage and selecting the ICD-10-CM code that specifically identifies the anatomical subsite of the esophagus.
Incorrect
Correct: In the TNM staging system for esophageal cancer, a tumor that invades the muscularis propria is classified as T2. Since 18 lymph nodes were examined and found negative, the nodal status is N0. The absence of distant metastasis is recorded as M0. For ICD-10-CM, the distal esophagus is synonymous with the lower third, which is specifically reported using code C15.5.
Incorrect: The classification of T1b is incorrect because it refers to invasion of the submucosa, not the muscularis propria; additionally, C15.4 refers to the middle third of the esophagus. T3 is incorrect because it requires invasion into the adventitia, and N1 is incorrect as it indicates regional lymph node metastasis, which was not present. Tis and D00.1 are incorrect because they refer to carcinoma in situ, which is limited to the epithelium and has not invaded the deeper layers like the muscularis propria.
Takeaway: Accurate coding for esophageal cancer requires correlating the pathological depth of invasion with the correct T stage and selecting the ICD-10-CM code that specifically identifies the anatomical subsite of the esophagus.
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Question 2 of 7
2. Question
As the privacy officer at a listed company, you are reviewing Esophagogastroduodenoscopy (EGD) – diagnostic and therapeutic during whistleblowing when an internal audit finding arrives on your desk. It reveals that for several patients, a snare technique was used to remove polyps in the antrum, but the encounters were coded as 43239 (EGD with biopsy). To ensure compliance with CPT guidelines and rectify the risk of under-coding or miscoding, which of the following represents the correct coding application for these therapeutic procedures?
Correct
Correct: CPT code 43251 (Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) is the specific code for snare removal. According to CPT guidelines, if a biopsy and a snare removal are performed on the same lesion, only the more complex procedure (snare removal) is reported. Reporting the snare removal ensures the therapeutic nature of the procedure is accurately captured.
Incorrect: Reporting both a biopsy and a snare removal for the same lesion constitutes unbundling, as the biopsy is considered incidental to the removal. Code 43250 is incorrect because it specifically refers to removal by hot biopsy forceps or bipolar cautery, which is a different technique than the snare technique described. Reporting a diagnostic EGD (43235) alongside a therapeutic code (43251) is incorrect because the diagnostic component is the base procedure and is bundled into the therapeutic service.
Takeaway: When a polyp is removed via snare technique during an EGD, the specific therapeutic code 43251 should be used, and separate biopsy codes for the same lesion should be avoided to prevent unbundling.
Incorrect
Correct: CPT code 43251 (Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) is the specific code for snare removal. According to CPT guidelines, if a biopsy and a snare removal are performed on the same lesion, only the more complex procedure (snare removal) is reported. Reporting the snare removal ensures the therapeutic nature of the procedure is accurately captured.
Incorrect: Reporting both a biopsy and a snare removal for the same lesion constitutes unbundling, as the biopsy is considered incidental to the removal. Code 43250 is incorrect because it specifically refers to removal by hot biopsy forceps or bipolar cautery, which is a different technique than the snare technique described. Reporting a diagnostic EGD (43235) alongside a therapeutic code (43251) is incorrect because the diagnostic component is the base procedure and is bundled into the therapeutic service.
Takeaway: When a polyp is removed via snare technique during an EGD, the specific therapeutic code 43251 should be used, and separate biopsy codes for the same lesion should be avoided to prevent unbundling.
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Question 3 of 7
3. Question
Excerpt from an internal audit finding: In work related to Jejunostomy tube placement/replacement as part of regulatory inspection at a fintech lender, it was noted that a clinical documentation review was conducted for a patient with esophageal adenocarcinoma. The patient had a percutaneous jejunostomy tube (PEJ) that became obstructed 30 days after the initial procedure. The physician replaced the tube through the existing percutaneous tract using fluoroscopic guidance to confirm placement. To ensure compliance with professional coding standards and regulatory requirements, which CPT code should the auditor identify as the correct reporting for this replacement procedure?
Correct
Correct: CPT code 49451 is the correct code for the percutaneous replacement of a jejunostomy tube when performed under fluoroscopic guidance. This code specifically includes the removal of the existing tube, the insertion of a new tube through the established tract, and the necessary fluoroscopic guidance, contrast injections, and image documentation required for the procedure.
Incorrect
Correct: CPT code 49451 is the correct code for the percutaneous replacement of a jejunostomy tube when performed under fluoroscopic guidance. This code specifically includes the removal of the existing tube, the insertion of a new tube through the established tract, and the necessary fluoroscopic guidance, contrast injections, and image documentation required for the procedure.
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Question 4 of 7
4. Question
The risk committee at a fintech lender is debating standards for Enteroscopy (single balloon, double balloon) as part of client suitability. The central issue is that the medical underwriting department must ensure precise coding for high-value claims involving deep small bowel exploration. In a recent case, a physician used a double-balloon enteroscope to reach the mid-jejunum via an anterograde approach to perform a biopsy of a suspected malabsorption site. The auditor is reviewing the documentation from the 60-minute procedure to verify the correct CPT assignment. Which of the following best describes the coding requirement for this balloon-assisted enteroscopy?
Correct
Correct: Balloon-assisted enteroscopy (BAE), which includes both single and double balloon techniques, has specific CPT codes that differentiate it from standard endoscopy. When the procedure is performed anterograde (through the mouth) and reaches the small intestine beyond the second portion of the duodenum (such as the jejunum) to perform a biopsy, the code specifically describing balloon-assisted enteroscopy with biopsy must be used. This reflects the increased complexity and specialized equipment required compared to a standard EGD.
Incorrect: A standard EGD code is incorrect because it only covers the esophagus, stomach, and the proximal duodenum; it does not account for the specialized balloon-assisted equipment or the depth reached in the jejunum. Retrograde enteroscopy is incorrect because it refers to an approach through the rectum and colon to reach the small bowel. Using an unlisted code is inappropriate because there are specific, established CPT codes for balloon-assisted enteroscopy procedures.
Takeaway: Coding for balloon-assisted enteroscopy requires distinguishing the approach (anterograde vs. retrograde) and confirming the scope reached the small intestine beyond the second portion of the duodenum.
Incorrect
Correct: Balloon-assisted enteroscopy (BAE), which includes both single and double balloon techniques, has specific CPT codes that differentiate it from standard endoscopy. When the procedure is performed anterograde (through the mouth) and reaches the small intestine beyond the second portion of the duodenum (such as the jejunum) to perform a biopsy, the code specifically describing balloon-assisted enteroscopy with biopsy must be used. This reflects the increased complexity and specialized equipment required compared to a standard EGD.
Incorrect: A standard EGD code is incorrect because it only covers the esophagus, stomach, and the proximal duodenum; it does not account for the specialized balloon-assisted equipment or the depth reached in the jejunum. Retrograde enteroscopy is incorrect because it refers to an approach through the rectum and colon to reach the small bowel. Using an unlisted code is inappropriate because there are specific, established CPT codes for balloon-assisted enteroscopy procedures.
Takeaway: Coding for balloon-assisted enteroscopy requires distinguishing the approach (anterograde vs. retrograde) and confirming the scope reached the small intestine beyond the second portion of the duodenum.
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Question 5 of 7
5. Question
An internal review at a fintech lender examining Coding for history of GI conditions as part of record-keeping has uncovered that several medical claims for follow-up endoscopic surveillance were flagged for audit. In one specific case, a patient who underwent successful endoscopic mucosal resection for localized esophageal adenocarcinoma two years ago returned for a surveillance esophagogastroduodenoscopy (EGD). The auditor noted that the claim was submitted using the code for active malignant neoplasm of the esophagus (C15.9), despite the physician documenting ‘no evidence of recurrence’ and the patient having completed all active treatment. Which coding approach is required to correctly reflect the patient’s clinical status according to ICD-10-CM guidelines?
Correct
Correct: According to ICD-10-CM guidelines, a personal history code (Z85-Z87) is used when a primary malignancy has been excised or eradicated, there is no further treatment directed to that site, and there is no evidence of any existing primary malignancy. Since the adenocarcinoma was resected and there is no evidence of recurrence, the active cancer code (C15.9) is no longer appropriate, and the history code (Z85.01) must be used to accurately reflect the patient’s status.
Incorrect: Reporting an active malignancy code when the disease is no longer present and treatment has concluded is a violation of coding accuracy and can lead to compliance issues. Screening codes (Z12 series) are reserved for patients who do not have a history of the disease being screened for; surveillance of a known past condition is not considered a screening encounter. Coding a stricture (K22.2) without clinical documentation of such a condition is inaccurate and does not represent the true reason for the surveillance encounter.
Takeaway: Personal history codes must be used when a condition is resolved and no longer receiving active treatment to distinguish surveillance from active disease management.
Incorrect
Correct: According to ICD-10-CM guidelines, a personal history code (Z85-Z87) is used when a primary malignancy has been excised or eradicated, there is no further treatment directed to that site, and there is no evidence of any existing primary malignancy. Since the adenocarcinoma was resected and there is no evidence of recurrence, the active cancer code (C15.9) is no longer appropriate, and the history code (Z85.01) must be used to accurately reflect the patient’s status.
Incorrect: Reporting an active malignancy code when the disease is no longer present and treatment has concluded is a violation of coding accuracy and can lead to compliance issues. Screening codes (Z12 series) are reserved for patients who do not have a history of the disease being screened for; surveillance of a known past condition is not considered a screening encounter. Coding a stricture (K22.2) without clinical documentation of such a condition is inaccurate and does not represent the true reason for the surveillance encounter.
Takeaway: Personal history codes must be used when a condition is resolved and no longer receiving active treatment to distinguish surveillance from active disease management.
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Question 6 of 7
6. Question
In your capacity as internal auditor at a wealth manager, you are handling Coding for obesity and related GI conditions during model risk. A colleague forwards you an internal audit finding showing that a portfolio company specializing in gastroenterology has been inconsistently reporting BMI (Body Mass Index) codes for patients diagnosed with morbid obesity and Gastroesophageal Reflux Disease (GERD). The audit identifies a risk of non-compliance with ICD-10-CM guidelines and potential impacts on risk-adjustment data. Which of the following actions should the internal auditor recommend to ensure the coding process aligns with official standards?
Correct
Correct: According to the ICD-10-CM Official Guidelines for Coding and Reporting, BMI codes (category Z68) should be reported as secondary diagnoses when an associated diagnosis such as obesity (category E66) is present. A unique aspect of these codes is that the BMI value can be documented by other clinicians involved in the patient’s care (such as a nurse or dietitian), provided the physician or qualified healthcare practitioner documents the associated condition (obesity).
Incorrect: Sequencing a BMI code as a principal diagnosis is incorrect because Z68 codes are always supplemental and secondary to the underlying condition. There is no regulatory requirement for a physician to explicitly link the BMI to the treatment of a specific GI condition like GERD for the code to be reported. Omitting BMI codes because they are considered inherent is a violation of coding instructions, which state that BMI codes should be used as additional codes to provide specificity to the obesity diagnosis.
Takeaway: BMI codes are supplemental secondary codes that can be supported by non-physician documentation but must always be paired with a provider-documented diagnosis of obesity or overweight.
Incorrect
Correct: According to the ICD-10-CM Official Guidelines for Coding and Reporting, BMI codes (category Z68) should be reported as secondary diagnoses when an associated diagnosis such as obesity (category E66) is present. A unique aspect of these codes is that the BMI value can be documented by other clinicians involved in the patient’s care (such as a nurse or dietitian), provided the physician or qualified healthcare practitioner documents the associated condition (obesity).
Incorrect: Sequencing a BMI code as a principal diagnosis is incorrect because Z68 codes are always supplemental and secondary to the underlying condition. There is no regulatory requirement for a physician to explicitly link the BMI to the treatment of a specific GI condition like GERD for the code to be reported. Omitting BMI codes because they are considered inherent is a violation of coding instructions, which state that BMI codes should be used as additional codes to provide specificity to the obesity diagnosis.
Takeaway: BMI codes are supplemental secondary codes that can be supported by non-physician documentation but must always be paired with a provider-documented diagnosis of obesity or overweight.
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Question 7 of 7
7. Question
Which characterization of Small intestine surgery is most accurate for Certified Gastroenterology Coder (CGIC)? A 54-year-old patient with a history of refractory Crohn’s disease presents for a planned resection of a diseased portion of the terminal ileum. During the procedure, the surgeon performs a partial enterectomy and a primary end-to-end anastomosis to restore intestinal continuity. When selecting the appropriate CPT code, which of the following reflects the correct coding principle for this scenario?
Correct
Correct: In CPT coding for small intestine surgery, codes such as 44120 (Enterectomy, resection of small intestine; single resection and anastomosis) inherently include the work of the anastomosis. Furthermore, the duodenum is anatomically and surgically distinct from the jejunum and ileum; procedures on the duodenum are often found in the 44000 series under different headings or even the stomach/biliary sections depending on the specific procedure, whereas jejunal and ileal resections are grouped together.
Incorrect: Reporting a separate code for anastomosis is incorrect because the primary enterectomy codes (44120-44125) specifically include the anastomosis in their descriptors. Using the partial colectomy series is incorrect because the ileum is part of the small intestine, and codes are assigned based on the organ being resected, not its proximity to others. Reporting the primary code twice for multiple segments is incorrect because CPT provides a specific add-on code (44121) for each additional resection and anastomosis after the first segment.
Takeaway: For small intestine resections, the primary anastomosis is bundled into the resection code, and coders must distinguish between duodenal and jejunal/ileal sites while utilizing add-on codes for multiple segments.
Incorrect
Correct: In CPT coding for small intestine surgery, codes such as 44120 (Enterectomy, resection of small intestine; single resection and anastomosis) inherently include the work of the anastomosis. Furthermore, the duodenum is anatomically and surgically distinct from the jejunum and ileum; procedures on the duodenum are often found in the 44000 series under different headings or even the stomach/biliary sections depending on the specific procedure, whereas jejunal and ileal resections are grouped together.
Incorrect: Reporting a separate code for anastomosis is incorrect because the primary enterectomy codes (44120-44125) specifically include the anastomosis in their descriptors. Using the partial colectomy series is incorrect because the ileum is part of the small intestine, and codes are assigned based on the organ being resected, not its proximity to others. Reporting the primary code twice for multiple segments is incorrect because CPT provides a specific add-on code (44121) for each additional resection and anastomosis after the first segment.
Takeaway: For small intestine resections, the primary anastomosis is bundled into the resection code, and coders must distinguish between duodenal and jejunal/ileal sites while utilizing add-on codes for multiple segments.
