CPT CODE and Description
30075-16  Biopsy of pancreas
30473-00  Panendoscopy to duodenum
30688-00  Endoscopic ultrasound
DOUBLE BALLOON ENTEROSCOPY
Double balloon enteroscopy (DBE) is an endoscopic technique that allows examination of the small intestine beyond the reach of other endoscopes.
** Revision of ACHI Index pathways to eliminate inconsistencies for double balloon enteroscopy (DBE) when performed via retrograde (per rectal) approach.
** Inclusion terms for balloon procedures at Index pathways for panendoscopy blocks  –  have been removed
** Creation of new code 30680-00 Balloon enteroscopy at block  Panendoscopy,
** Assign 30680-00  Balloon enteroscopy in conjunction with interventions classified to blocks , , ,  and  when performed with double balloon enteroscopy.
30473-00  Panendoscopy to duodenum
As per WA Coding Rule 0316/09 Double balloon enteroscopy, effective 30 Mar 2016 – 30 Jun 2019, no look up exists at ‘Jejunoscopy’, so the lead term ‘Enteroscopy’ must be used, leading to the assignment of a panendoscopy code.
INSTRUCTION FOR PANENDOSCOPY
1. If you are Diabetic, please contact the physician that manages your diabetes. They will give you instructions for adjusting your medications for the prep. Let your
physician know you will not be eating/drinking anything after midnight.
2. Take all medications for your heart or blood pressure the morning of the test, with a sip of water. Do NOT take any diuretics (water pills). Examples: Furosemide
(Lasix), Hydrochlorothiazide (HCTZ), Diuril, Aldactone…..
3. If you take blood thinners (Aspirin, Coumadin, Plavix, etc. ), please be sure we are aware of this. We will contact your prescribing doctor for specific instructions.
4. Due to sedation used during the exam, you will not be able to drive or return to work the day of your procedure.
1. Eight (8) hours prior to your arrival time: NO solid foods.
NO milk or milk products. NO red dyes. NO alcoholic beverages or beer. You can continue the clear liquids for four (4) more hours.
2. Four (4) hours before your arrival time: Stop all clear liquids.
3. Take your medications with a sip of water, at least two hours before your arrival time.
4. Bring with you: current medication list, photo ID, insurance cards, and the blue questionnaire.
Clear liquids are allowed up to 4 hours before your arrival time:
Water, clear fruit juices (apple, white grape, white cranberry), bouillon, Jell-O (NO red Jell -O or fruit added), Ginger ale, Fresca, Coke/Pepsi, Gatorade (NO reds), Kool-Aid, SevenUp, Popsicles, or tea (no milk).
Before your Procedure
There are a few things that we ask all patients to do prior to coming in for their endoscopic procedure:
* Please follow all instructions given to you by your physician about eating, drinking and medications before your procedure. FOLLOW OUR INSTRUCTIONS, NOT WHAT COMES IN THE PREP BOX.
* If you are taking any medications, or if you are allergic to any medications, please bring a list of them with you when you come for your procedure.
* If you take any blood thinners and have not been instructed regarding usage prior to your procedure, please contact your physician as soon as possible.
* Notify your physician if there have been any changes in your physical condition since your last appointment was scheduled or since you last saw your physician.
* Please do not arrive prior to 6:45 am
Please be considerate of other patients and your physician by calling our office as soon as possible if you cannot keep your appointment. We understand that circumstances beyond your control may arise, exceptions will be made in the event of inclement weather or real emergencies Every health plan is different. While we make every effort to obtain referrals from primary care physicians and authorizations for outpatient procedures, it is also important for you to be familiar with your health care coverage.
We cannot be held responsible for unpaid services due to lack of referral or prior authorization.
A panendoscopy is the examination of the upper aerodigestive tract (pharynx, larynx, upper trachea and oesophagus). It may also involve the removal or biopsy of any abnormal tissue found.
Patient Information Panendoscopy and Biopsy
What is a panendoscopy and biopsy?
This operation is usually performed when there is suspicion of a cancer within the head and neck. It allows the surgeon to fully assess the oral cavity, larynx (voicebox) and oesophagus (food-pipe) to identify the extent of any growths, and take biopsies (which can include a tonsillectomy) to aid in diagnosis.
What is the operation like?
This is usually a day stay procedure. Before the operation you will see a member of the surgical team and the anaesthetist. The operation is performed with you asleep under a general anaesthetic for approximately 20 minutes.
You will wake up in the recovery room and once the anaesthetic has worn off you will be seen by your surgeon to explain the findings. If there are no significant problems you will then be discharged home with painkillers and an appointment to come back for any biopsy results. You will have a sore throat (especially if tonsillectomy was performed), and this will gradually improve over a week or two.
What can go wrong ?
The surgery is usually safe and uncomplicated however it is important that you are aware of the risks of the procedure.
General complications such as nausea, vomiting, sore throat and drowsiness may occur as a result of the anaesthetic. Serious drug reactions related to the anaesthetic are very rare.
What is the correct code to assign for a nasendoscopy with views to the larynx** Should the instruction in ACS 0024 Panendoscopy to code to the furthest site viewed be applied to assign a code for laryngoscopy?
Panendoscopy is a generic term for an endoscopy of the upper gastrointestinal tract (ie oesophagus, stomach and duodenum) or aerodigestive tract (ie pharynx, larynx, upper oesophagus). ACS 0024
The term panendoscopy can also be used to mean endoscopies of the respiratory tract and the urinary system and therefore nongastrointestinal endoscopies should be coded appropriately, to the furthest site viewed
This advice only applies where the term panendoscopy is documented. Where specific types of endoscopes (nasendoscopy, laryngoscopy) are documented these should be coded as such. For example, if documentation indicates a nasendoscopy with views to the larynx has been performed, assign 41764-00  Nasendoscopy. A separate code from block  Examination procedures on larynx should be assigned if documentation indicates a laryngoscopy has also been performed.
What is the correct procedure code for biopsy of a lesion using EUS guidance?
Endoscopic ultrasound (EUS) is similar to other endoscopies but with an ultrasound probe attached at the end of the endoscope, which permits both visualisation and tissue sampling of gastrointestinal walls and structures surrounding the gastrointestinal tract. EUS is primarily used for assessing lesions in the gastrointestinal tract, but has increasingly been used for evaluating lesions of adjacent organs such as lung, mediastinum, left kidney, adrenal gland and lymph nodes (intra-thoracic and intra-abdominal).
When biopsy of a lesion is performed under EUS guidance, assign an appropriate code for the type of endoscopy (e.g. gastroscopy, gastroscopy with biopsy) and 30688-00  Endoscopic ultrasound. For example, EUS guided FNA (fine needle aspiration) biopsy of pancreas, assign:
30075-16  Biopsy of pancreas
30473-00  Panendoscopy to duodenum
30688-00  Endoscopic ultrasound
Coding and Billing
At this time, TNE uses the same coding procedures as conventional endoscopy. Diagnostic TNE (43200) and TNE with biopsy(s) (43202).
TNE Versus Conventional Esophagoscopy
Since the introduction of TNE, there have been many studies comparing TNE with the ‘‘gold standard’’ of conventional esophagoscopy (CE), which is performed transorally with sedation. Studies utilizing small-caliber video endoscopes have almost all concluded that TNE image quality and diagnostic capability is equivalent to CE, and that the majority of patients prefer TNE to CE.94–102
A summary review of these and other comparative studies was recently published as a portion of the American Academy of Otolaryngology position paper on TNE.82
TNE is also less expensive than CE. The increased direct costs of CE include longer procedure time, recovery room and recovery time, and the costs associated with medications, monitoring, and nursing.103 The difference in cost has been found to be greater than $2,000 per procedure.104 Indirect costs are also important but
difficult to quantify. This includes loss of work time by both the patient and a driver or caretaker. In contrast, with TNE, most patients are able to return to work or home shortly after the completion of the examination and do not need a caretaker.
Studies have shown a very high patient satisfaction rate, often greater than with CE.81,93 Crossover studies have shown that in patients who had both sedated and
unsedated examinations, the unsedated transnasal endoscopy was better tolerated.97
We anticipate that the future will bring continued refinements, such as still smaller endoscopes and the development of novel instruments to be used in conjunction with them. In addition, new techniques in imaging have emerged showing promise for enhancement and better visualization of the microvascular patterns of mucosal surfaces. Of particular interest is NBI optical technology, as noted earlier.105,106 NBI employs the filtering of light into three narrow bandwidths. This allows for optimal visualization of surface capillary and mucosa patterns, which the literature has suggested may allow for better evaluation and diagnosis of esophageal lesions. This may very well lead to improvement in the diagnosis of Barrett’s metaplasia, adenocarcinoma, and head and neck squamous cell cancer.
In-office TNE has become an important part of the evaluation and management of patients with dysphagia, extraesophageal/gastroesophageal reflux disease, and head and neck cancer. TNE provides a number of advantages over conventional endoscopy with equivalent clinical results. These advantages are improved safety, decreased overall costs, and patient preference.
MISCELLANEOUS LARYNGEAL PROCEDURES IN THE OFFICE SETTING
The revival of interest in awake laryngeal techniques has led to the development of additional procedures that offer novel value in care of the laryngology patient.
Perhaps the largest and most widely applicable is awake laryngopharyngeal biopsy. Although its roots are over 100 years old, awake laryngeal biopsy has seen a resurgence with the development of new endoscopes, endoscope sheaths, and instrumentation. Until approximately 15 years ago, the primary means for awake
laryngopharyngeal biopsy was similar to the approach used by the fathers of laryngology in the mid 1850s: transoral passage of long curved biopsy forceps with
indirect mirror laryngoscopy guidance. Although visualization is now achieved with rigid or flexible endoscopes with video display of the image rather than laryngeal
mirrors, the technique remains largely unchanged. However, in addition to the peroral biopsy approach, laryngeal biopsy can be done via the working channel of a flexible endoscope.
After adequate laryngopharyngeal anesthesia (as described previously), the patient is positioned sitting upright in the sniffing position. When using a rigid endoscope transorally, the patient holds their tongue protruded. The otolaryngologist holds the rigid endoscope in one hand and the biopsy forceps in the other.
The patient is asked to breathe comfortably through their mouth as the forceps are introduced into the laryngeal introitus. The forceps are directed to the biopsy site and a representative sample is taken. Today, this still remains a valuable tool for the otolaryngologist, but requires skill and patience on the part of the otolaryngologist and patient.
With the introduction of flexible channeled endoscopes or flexible endoscopes with a channeled sheath (Medtronic ENT, Jacksonville, FL), the procedure has become considerably better tolerated by patients and easier to perform. The patient is anesthetized and positioned similarly to the previous descriptions. The flexible laryngoscope is passed transnasally and held in position viewing the biopsy target. A 2.0-mm flexible cup forceps is introduced by an assistant through the channel of the endoscope or the endosheath until they appear several millimeters beyond the tip of the scope (Fig. 15) (Olympus Biopsy Forceps, SB-34C-1, 1.8 mm diameter, 1050
mm length. Olympus America, Center Valley, PA). The forceps are opened and then the endoscope is advanced onto the target. The assistant closes the forceps and the sample is taken. The specimen can be withdrawn via the forceps, leaving the endoscope in place most of the time, which facilitates a rapid additional biopsy if needed. If the biopsy tissue is very large, then the entire endoscope can be withdrawn, allowing the specimen to be placed in the collection cup without being withdrawn through the working channel.
When combined with transnasal esophagoscopy and bronchoscopy, awake panendoscopy, staging, and biopsy has become a reality. Awake laryngeal biopsy and tumor staging has been demonstrated to be equally as effective as operative staging.83,107 Time from presentation to initiation of treatment is reduced by elimination of the traditional panendoscopy and biopsy under general anesthesia. Patients are spared from additional general anesthesia, physician efficiency is improved, and healthcare costs are reduced. Additional value of awake laryngeal biopsy lies in the evaluation and surveillance of laryngeal lesions that do not warrant operative excision, and culturing of lesions suspicious for bacterial or fungal infection.