Endoscopy vs. Manipulation: A Complete Guide to Upper GI Dilations

Brand names can help to guide you -- here’s how
When reporting upper gastrointestinal (GI) dilation procedures, you won’t always find the code you need in CPT’s "digestive system, manipulation" subsection. In some cases, you will instead choose an endoscopic procedure code. And in other cases, you may report a scope and a manipulation.

No Scope Means Manipulation Only

If the outpatient physician does not use a scope during the upper GI dilation, you should report a manipulation code (43450-43458) only, says Margie Pfaff, CPC, corporate compliance analyst for Wisconsin’s Medical Associates Health Centers. To determine which of these codes is appropriate to the circumstances, you must carefully check the physician’s documentation.
Look for key terms: When reviewing the physician’s notes, look for the descriptors "bougie" (which is a type of flexible dilator) and "Maloney" or "Hurst" (which refer to the bougie’s shape). If you encounter any of these terms, you should probably use 43450 (Dilation of esophagus, by unguided sound or bougie, single or multiple passes: APC 0140) for the insertion of a dilator or series of dilators.
Achalasia diagnosis provides another hint: Achalasia causes spasm and lack of relaxation of the lower esophageal sphincter (LES) muscle. Therefore, physicians must often use a larger, balloon-type dilator to treat this problem. You can report dilations of this type (without an upper gastrointestinal endoscopy, EGD) using 43458 (Dilation of esophagus with balloon [30-mm diameter or larger] for achalasia: APC 0141).

Watch for Guidewire and Balloon/Dilator Option

In the rare case when the physician inserts a dilator over a guidewire without using a scope, you should report 43453 (Dilation of esophagus, over guidewire: APC 0140). More often, however, the physician will use an endoscope to place the guidewire, which calls for different coding (see "Turn to 43226, 43248 for Guidewires" below).
Key term: When you see the terms "Puestow dilator" or "Puestow rod," you can be fairly sure that 43453 is the correct code.
Best advice: As a coder, you should be aware of brand names, says Diana Quicker, finance coordinator of Gastroenterology Associates of Sarasota in Florida.-
For the rare transgastric intraoperative retrograde (reverse direction) dilation using a balloon or dilator without a scope, you should apply 43456 (Dilation of esophagus, by balloon or dilator, retrograde: APC 0140). Most often a general surgeon would perform this procedure. For endoscopic balloon dilations, your code choice will differ (see "Balloon Dilator Calls for 43220 or 43249" below).

Report Scope for Visualization Separately

If the physician performs an endoscopy for visualization or other purposes (such as biopsy) prior [...]

- Published on 2008-02-12