|Small bowel follow through CPT codeIn radiology, we have few codes which are little tricky to understand. Here, we are discussing about Upper GI codes which are difficult to code. These codes are already discussed in my previous post. But, I am here to discuss only the Small bowel follow through CPT codes. These codes are coded very frequently with radiology charts. These exams are done to diagnose disorders related to esophagus. There are only two CPT Codes used for small bowel follow through. Single and double contrast is the only difference between small bowel follow through CPT code. Below are the CPT codes used for small bowel follow through
74245– Radiologic examination, gastrointestinal tract, upper; with small intestine, includes multiple serial films
74249– Radiological examination, gastrointestinal tract, upper, air contrast, with specific high density barium, effervescent agent, with small intestine follow-through
As per the above code description, it is very clear that small intestine is examined along with upper GI tract for small bowel follow through exam.
Now to code these CPT codes one has to only differentiate between single and double contrast. For single contrast there will clearly mention of single contrast in the medical report. For double contrast they can speak about Air contrast or effervescence crystal or granules in the medical report. Sometimes they will directly say double contrast was used. So, the documentation in the report is the key to find out the correct CPT code.
Sample report for Small Bowel Follow Through
INDICATION: Abdominal pain, other specified site
SINGLE CONTRAST UPPER GI WITH SMALL BOWEL FOLLOW-THROUGH STUDY
HISTORY: Abdominal pain. History of hiatal hernia and regional enteritis. Previous cholecystectomy.
FINDINGS: Scout image obtained demonstrates normal bowel gas pattern. Severe degenerative changes throughout the visible portion of the spine with levocurvature in the upper lumbar spine. Technically difficult study to perform due to patient’s large body habitus and relative immobility. The patient is able to drink barium without difficulty for this study. The esophagus is normal in course and caliber. Hiatal hernia is noted. Gastroesophageal reflux is visualized on several occasions during the study. Gastric folds as well as duodenal bulb and sweep appear normal. Contrast material is clearly evident in the transverse colon on the 45- minute image and is also seen in the splenic flexure area on the 30- minute image. Some contrast material is visible all the way into the rectum by 1 hour. Bowel loops are normal in caliber demonstrating normal mucosal pattern. I do not identify a fistula. The terminal ileum is difficult to identify. At the end of the study, the patient is able to swallow a 13 mm barium tablet without difficulty. It passed promptly through the esophagus and into the stomach.
IMPRESSION: Moderately large hiatal hernia with gastroesophageal reflux again noted. Small bowel appears within normal limits. Transit time is about 30 minutes.