Gastroenterology Coding Alert

Discover how to code these 4 distinct dilation types

If you-re staring endlessly at your physician's notes in an effort to decipher terms such as -Maloney,- -Hurst- and -Savary,- then you probably need to broaden your dilation coding lingo.

Focus: To determine which code you need, you must understand the difference among these dilation techniques.

What happens with dilations: The gastroenterologist will evaluate the stricture and decide between several types of dilators. The dilator choice depends on the stricture's size and characteristics, the physician's judgment, and the patient's history.

1. Isolate These Bougie Dilator Codes

Gastroenterologists perform some dilations with endoscopes and others without endoscopic guidance. In the latter, which you would code as manipulations, the physician may use an endoscope to visualize the stricture but remove it before he does the dilation. Also, he may use a fluoroscope to guide the dilator's placement.

What to look for: When reviewing the physician's notes, look for the term -bougie,- -Maloney- or -Hurst.- Bougies are flexible dilators available in increasing thicknesses. A physician inserts these dilators into the esophagus in successively increasing diameters to open a stricture gradually. The bougie diameter can be stated in millimeters or in -french.- Note: French is another scientific measurement format. In other words, 1 mm = 3 Fr. The physician may also refer to a bougie based on its shape as -Maloney- or -Hurst.-

Bougies defined: Physicians use bougie dilators when they know the stricture type, site and size from a previous endoscopic procedure or barium swallow x-ray. These strictures tend to be less tight than those requiring directed endoscopic manipulation. Whenever the operative notes articulate these circumstances, start looking to 43450 (Dilation of esophagus, by unguided sound or bougie, single or multiple passes).

You should report 43450 for the insertion of a dilator or series of dilators. If the gastroenterologist performs an endoscopy before the dilation, you should report it separately, says Shonna Heath of North Country Gastorenterology in St. Littleton, N.H.

Example: The physician performs an esophagogastroduodenoscopy (EGD) with biopsy (43239) before inserting a Maloney dilator. Report 43239 first because it has a higher relative value, and expect 100 percent reimbursement from Medicare. Report 43450 with modifier 51 (Multiple procedures) appended and expect 50 percent of the standard fee if you follow Medicare's multiple-procedure rules (see -Simplify the Multiple- Endoscope Family Rule With This Expert Advice- on page 45 for more information on the multiple-procedure rule).

Don't miss: You can code for fluoroscopic guidance when the physician uses a fluoroscope during the procedure, says Jan Simms, CPC, CGCS, coder for Birmingham Gastro Associates PC in Alabama.

For the above example, you should report 74360 (Intraluminal dilation of strictures and/or obstructions [e.g., esophagus], radiological supervision and interpretation) with modifier 51 attached. Reimbursement will be 50 percent of the standard fee here, also.

2. Get This Guidewire Insertion Scenario

Gastroenterologists also use bougies with guidewires. For this procedure, the physician performs an endoscopy, places the guidewire through the endoscope, and removes the endoscope leaving the wire in place. Then, he guides the bougie along the wire, which he removes when the procedure is complete. A physician performs this type of dilation when the strictures are tight or irregularly shaped, experts say. 

Your physician may refer to this endoscopic procedure by the brand names -Savary- or -American- in his notes. Best advice: As a coder, you should make yourself aware of brand names, says Diana Quicker, finance coordinator of Gastroenterology Associates of Sarasota in Florida. 

When you identify this type of procedure, you should use 43248 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with insertion of guidewire followed by dilation of esophagus over guidewire) or 43226 (Esophagoscopy, rigid or flexible; with insertion of guidewire followed by dilation over guidewire).

In rare cases, the physician may insert a dilator over a guidewire without using an endoscope. The appropriate code for this is 43453 (Dilation of esophagus, over guidewire). Physicians use fluoroscopes with this procedure to visualize the guidewire placement. You can report this service with 74360.

3. Use 43220 With Balloon Dilations

Another common type of dilation involves a balloon dilator, which the physician inserts with the aid of an endoscopy. When the physician's notes say that she placed a deflated balloon dilator through the endoscope and gradually inflated the dilator to open the stricture, look to 43249 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with balloon dilation of esophagus [less than 30 mm diameter]) or 43220 (Esophagoscopy, rigid or flexible; with balloon dilation [less than 30 mm diameter]). Balloon dilators for esophageal strictures come in many styles and sizes, ranging up to about 20 mm.

You should report these dilations using 43249. -You-ll use this code if your gastroenterologist visualizes the stomach and duodenum,- Simms says. In other words, the endoscope passes the esophageal stricture and enters the stomach and duodenum.

If the endoscopic balloon dilation does not allow the scope to pass into the stomach, you should use 43220. When the physician passes the endoscope into the stomach and then dilates the upper esophagus before removing the scope, you can report 43249.

4. Achalasia Requires Unique Code: 43458

The above-mentioned dilators are not large enough to treat some disorders. For example, achalasia is a condition marked by spasm and lack of relaxation of the lower esophageal sphincter (LES) muscle. Gastroenterologists use a larger, balloon-type dilator to treat this problem. Upon gradual expansion, the dilator eventually ruptures the muscle.

You report this procedure with 43458 (Dilation of esophagus with balloon [30 mm diameter or larger] for achalasia). Fluoroscopy often accompanies this dilation procedure, and you can report this with 74360 (Intraluminal dilation of strictures and/or obstructions [e.g., esophagus], radiological supervision and interpretation).

Many doctors perform EGDs (43235) to visualize the esophagus and insert the balloon. You should report this procedure separately. Reimbursement will follow Medicare's multiple-procedure rule, under which the carrier reimburses each subsequent procedure at 50 percent of the standard fee. Code the following:

- 43458

- 43235-51

- 74360-51.