Gastroenterology Coding Alert

Dilations are performed when a portion of the esophagus has become closed due to ailments such as reflux esophagitis -- associated scarring, following radiation therapy for cancer, from caustic ingestions or medications associated with ulcerations (such as Fosamax, Quinaglute) or a disease called achalasia. Patients with esophageal webs or rings that interfere with swallowing also frequently require dilation. Different types of dilators as well as some variations on their use can confuse coders. In addition, gastroenterologists may refer to the dilator they used by a brand name, and coders may be uncertain which CPT code is correct.
 
"Coders need to know what type of dilator was used and any other procedure the physician performed," says Roberta Classen, CPC, CPC-H, AAPC National Advisory Board member and financial manager of Charleston Gastroenterology Specialists in Charleston, S.C. "Sometimes the confusion comes from the physician's interpretation of what was done."
 
In performing dilation, the gastroenterologist must first evaluate the stricture and then decide what type of dilator to use, notes David Johnson, MD, a gastroenterologist with Digestive & Liver Disease Specialists in Norfolk, Va.
 
"The choice of dilator depends on the size and dynamics of the stricture and the physician's clinical judgment," Johnson says. "The patient's history also could play a part in the decision."

 
Gastroenterologists use three basic types of dilators, Johnson explains, and each has its benefits based on the treatment approach dictated by the stricture's characteristics and cause. Some dilations are done with endoscopy, while others are not. Dilations without endoscopy are typically referred to and coded as manipulations. CPT 2001 includes a group of codes (43450-43458) in the surgery/digestive system section under the heading of manipulation. Codes for endoscopic dilations are in the endoscopy group of codes in the CPT manual.
 
Basic Bougie Provides Flexibility

 
Bougies are simple, flexible dilators that are available in increasing thicknesses. They may be passed down through the esophagus in succession to open the stricture gradually. Simple dilation with a bougie is often done in the gastroenterologist's office. The patient is placed in a sitting position, and an anesthetic spray is applied to the throat.
 
In describing this basic dilation procedure, the physician may use the names "Maloney" or "Hurst" to describe the dilator. These are both bougies, but they are distinguished by the shape of their tips, explains Peter Pardoll, MD, a gastroenterologist with the Center for Digestive Diseases in St. Petersburg, Fla., and co-founder of the National Gastroenterology Carrier Advisory Committee. The Maloney dilator's tip is pointed and the Hurst dilator's tip is more blunt.
 
"Use of the Maloney or Hurst dilators has gone by the wayside somewhat," he says. "More often you see dilations aided by endoscopy where we place a guide wire through the endoscope, then the scope is removed and the dilator runs over the guide wire."
 
Dilation with a bougie is reported with 43450 (dilation of esophagus, by unguided sound or bougie, single or multiple passes), according to Classen. The exam with a bougie is known as bougienage. If the physician performs endoscopy first, the endoscopy should be reported with 43235 (upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]). Be sure to use modifier -51 (multiple procedures) on the code with the lower relative value unit (RVU) (43450-51).
 
"The Pustow dilator is a rod with a small olive-shaped tip that is often used with very tight or small strictures such as those caused by cancer," Pardoll says. "The Pustow rod with varying-size metal tips is passed sequentially over a guide wire that is placed through the tight stricture endoscopically or with the use of fluoroscopy."
 
Pardoll adds that use of the Pustow dilator is reported almost exclusively with 43453 (dilation of esophagus, over guide wire).

 
The second type of dilator is a bougie used with a guide wire. The physician first performs an endoscopy, placing the guide wire through the endoscope. The endoscope is then removed and the wire remains in place. A bougie with openings at both ends is guided along the wire, which is subsequently removed when the procedure is complete. Pardoll says dilation with guide wires has become more common than simple dilation with a bougie.
 
"Savary" is one common brand name of guide wire bougie, Classen says. Pardoll references "American" or "American Endoscopy" as another.
 
Classen says dilation using a guide wire is usually reported with an endoscopy (i.e., 43248, upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with insertion of guide wire followed by dilation of esophagus over guide wire).
 
Balloon Dilators Allow for Gradual Increases

 
Balloon dilators are also inserted with the aid of endoscopy. A deflated balloon dilator is placed through the endoscope and gradually inflated to stretch and open the stricture. The balloon is inflated to a diameter of less than 30 mm.
 
"Balloon dilators allow for sequential increases of dilation as you gradually inflate the balloon, and they tend to be more comfortable for the patient," Johnson notes.
 
Classen says balloon dilation with endoscopy is reported using 43249 ( ... with balloon dilation of esophagus [less than 30 mm diameter]).
 
Note that 43249 describes the endoscope passing through the esophagus, the stomach and the duodenum. The gastroenterologist may choose to do this and then dilate the upper esophagus before removing the scope. If the balloon dilation does not include passing the scope into the duodenum, it should be reported using 43220 (esophagoscopy, rigid or flexible; with balloon dilation [less than 30 mm diameter]).
 
Special Dilator for Achalasia
 
 
A fourth type of dilator is used exclusively for treating achalasia, a condition marked by spasms of the lower esophageal sphincter (LES) muscle and the lack of relaxation of the LES. Achalasia is sometimes treated with a larger, balloon-type dilator, which stretches and eventually ruptures the muscle at the end of the esophagus, Pardoll says. Dilation in achalasia cases is guided with the aid of fluoroscopy.
 
Classen suggests dilation for achalasia be reported with 43458 (dilation of esophagus with balloon [30 mm diameter or larger] for achalasia). The fluoroscopy that accompanies this procedure could be reported with 74360 (intraluminal dilation of strictures and/or obstructions [e.g., esophagus], radiological supervision and interpretation). Many doctors also perform an endoscopy with this, and that needs to be reported separately.

 
The bottom line for avoiding confusion when coding dilations is to get comfortable with what your physician does, Johnson advises. Ask him or her for clarification.
 
Pardoll echoes that advice. "The physician is the only one who knows what he or she did," Pardoll says. "If you get to know the physician's preferences, there should be no confusion."
 
Pardoll places responsibility for accuracy on the physician's shoulders. He recommends the use of a small, pocket-size tape recorder to dictate a report immediately following the procedure and then handing the tape over to the coder.
 
"That's what I do, and I've never had a coder come back with a question," he says. "If you dictate the report right after the procedure, you're more likely to recall everything and less likely to lose reimbursement."