# EGD with Dilation



## mhcpc (Sep 2, 2009)

Help, Please?  I have the following:

DESCRIPTION OF PROCEDURE:  After informed consent was obtained, the patient   
    was placed in the supine position in the radiology suite.  After adequate   
    sedation had been achieved, the endoscope was inserted over the tongue and   
    through the posterior pharynx under direct visualization into the   
    esophagus.  In the mid esophagus, a very tight stricture was found, which   
    would not allow passage of the scope.  Under fluoroscopy, a Savory   
    guidewire was placed through this and into the stomach.  The stricture was   
    then dilated with passage of a 27 French gauge Savory dilator without   
    resistance.  A 36 French gauge dilator passed with moderate resistance.  A   
    42 French gauge Savory dilator would not pass without excessive resistance.   
    The scope was reinserted.  Only a very small amount of mucosal trauma was   
    identified.  A CRE balloon was then inserted and under visualization, it   
    was placed into the stricture.  This was inflated to 12 mm and held for one   
    minute.  The balloon was then deflated.  The scope was able to be slightly   
    advanced about 2 cm but then stopped.  The balloon was reinflated to 12 mm   
    and held for an additional minute. The scope would not pass through the   
    stricture at this point.  The balloon was then reinflated to 13.5 mm and   
    held for one minute and finally to 15 mm and held for one minute.   
    Unfortunately, when the balloon was deflated and withdrawn, the scope still   
    would not pass through the stricture.  A decision was, therefore, made to   
    terminate the endoscopy.   



I have never had a physician use 2 different types of dilation.  I know they aren't bundled, but can we charge both?  I know there will have to be a 53 modifier used since he had to terminate the procedure, but how would you code?

Thanks,

Michele Hayes, CPC, CGIC


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## cindyk (Sep 2, 2009)

Michele, you cannot bill for both endoscopies.  Either one or the other if it is the same lesion, which in this case it is.  Choose the one with the higher RVU and bill for that.  Hope this helps!


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## mhcpc (Sep 2, 2009)

That's what I thought.  Thanks for the confirmation


Michele


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