# multiple dilation help!



## ASC CODER (Nov 23, 2009)

I am new to gastro coding so I just want to make sure I am doing it right.


CLINICAL INDICATION: Cervical dysphagia, distal dysphagia, probable cervical web, possible distal stricture.

DESCRIPTION OF PROCEDURE:
Upon obtaining informed consent, the patient was given MAC anesthetic - see anesthesia report. The Fujinon endoscope was introduced into the small intestine. The patient had a gastrectomy and Bill Roth I anastomosis. The gastroenterostomy, remaining stomach, and enterostomy were all normal. Retroflexion revealed a hiatal hernia. There was a distal stricture. This was dilated with a 60 Fr balloon dilator 30 seconds x two. The esophagus was normal. There was no evidence of esophagitis. In the upper esophagus one could see a constriction consistent with a cervical web. This was dilated to a 54 Fr balloon dilator when one could see disruption of the stricture with some minimal bleeding, which is normal after post-stricture dilatation. The instrument was then withdrawn. The patient tolerated the procedure well. 

IMPRESSION:
Dysphagia primarily due to an upper cervical web - dilated to 54 French.
Hiatal hernia and distal stricture - dilated to 60 French.

PLAN:
We will review medications to make sure that she does not have any medication that is exacerbating her reflux and causing strictures.
Follow up with me in the office. 

43235  787.29 553.3
43450  787.29  530.3
43450 59  553.3 530.3

some instruction would be appreciated


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## ASC CODER (Nov 24, 2009)

Could someone give me direction please


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## j.berkshire (Nov 25, 2009)

Patients with altered anatomy, as this record indicates can be a bit challenging.  The distal stricture appears to be at the altered gastric outlet.  Look at CPT 43245 for this intervention.  For the esophageal stricture, it appears as if a through-the-scope balloon dilator was used.  Look at CPT 43249.  Your choice of code 43450 is for dilation only without the use of an endoscope.  I would ask the physician if the verbiage of these two codes describes what was provided.


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## ASC CODER (Nov 25, 2009)

Thank you!!!


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