Gastroenterology Coding Alert

Optimize payments by looking specifically for the use of fluoroscopy.

If your gastroenterologist performs esophageal dilations using different techniques and includes associated procedures, then you have an array of codes from which to choose. Narrow your options with this expert advice.

Look for Balloon Dilation in Documentation

Often, your gastroenterologist will perform a dilation procedure during endoscopy. One of the methods that your gastroenterologist will use for dilation during endoscopy is balloon dilation. When your gastroenterologist uses balloon dilation, delve deeper into the documentation to check:

• The extent to which your gastroenterologist visualized using the endoscope
• The type of balloon used
• The condition that required dilation

If only the esophagus was visualized, then you need to report the procedure using 43220 (Esophagoscopy, rigid or flexible; with balloon dilation [less than 30 mm diameter]). If your gastroenterologist visualized beyond the pyloric channel into the stomach, duodenum, and/or the jejunum, then you need to report the procedure using 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]).

Caution: The above mentioned codes can only be used when balloon dilation is done up to a diameter of 30 mm. If your gastroenterologist dilates the balloon greater than 30 mm as is done in the case of a person suffering from achalasia (to break open the muscle fibers of the lower esophageal sphincter), you need to report this procedure using 43458 (Dilation of esophagus with balloon [30 mm diameter or larger] for achalasia).

"With any esophageal dilation procedure there is the significant risk of perforation of the esophageal walls, so your gastroenterologist will often use endoscopy during the procedure to help decrease complications," says Michael Weinstein, MD, Gastroenterologist at Capital Digestive Care in Washington, D.C., and former representative of the AMA's CPT® Advisory Panel."Some types of dilation can be done with the scope in place and in others the scope is removed after a guidewire is inserted and before dilation is performed." You need to report the endoscopy separately 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]).

Example: Your gastroenterologist decides to perform a dilation procedure for a patient suffering from dysphagia due to eosinophilic esophagitis not responding to previously prescribed proton pump inhibitors and oral budesonide. Your gastroenterologist performs an esophagoscopy along with TTS balloon dilation (Through The Scope) to relieve the dysphagia symptoms that the patient is experiencing. You report the procedure using 43220.

Capture These Codes for Guide Wire Dilations

Owing to the difficulty of passing the dilators and their correct placement for overcoming strictures, your gastroenterologist might use guide wires prior to the use of a dilator. These guide wires might be placed using an endoscope. In such a scenario, you will again have to determine the extent to which the scope was advanced to arrive at the right code for the procedure.

So you report 43226 (Esophagoscopy, rigid or flexible; with insertion of guide wire followed by dilation over guide wire) if only the esophagus was visualized and choose 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) if your gastroenterologist advanced the scope beyond the pyloric channel.

Coding Tip: If you see the word "American" or "Savary" to describe the dilator that is used, then you can be assured that your gastroenterologist used a guide wire prior to the dilation procedure.

Settle For These Codes to Report Unguided Dilations

When your gastroenterologist uses a dilator without using the aid of endoscopy or a guide wire or performs a diagnostic endoscopy that is removed prior to the use of a dilator, you need to report the procedure using 43450 (Dilation of esophagus, by unguided sound or bougie, single or multiple passes). If your gastroenterologist performed an endoscopy prior to the procedure, then you need to report it separately using 43235 or 43200 (Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) depending on the extent of the visualization."If a biopsy or other endoscopic therapeutic technique was performed then you will choose the appropriate code from the Esophagoscopy or Upper Gastrointestinal Endoscopy family of codes," Weinstein adds.

Coding Tip: If you see the use of a "Maloney" dilator, then you can be certain that your gastroenterologist performed an unguided dilation (43450) and choose one of the above mentioned codes to report the endoscopy portion of the procedure.

In the rare case that your gastroenterologist performs dilation over a guide wire that was not placed using an endoscope, you will need to report the procedure with 43453 (Dilation of esophagus, over guide wire).

Don't Forget to Report Fluoroscopy Separately

In many instances, your gastroenterologist will choose to take the help of fluoroscopy for the placement of the dilators in the correct position prior to their use. In such a scenario, don't forget to report the supervision and interpretation of the fluoroscopy separately in addition to the dilation procedure that you are reporting. You will need to use 74360 (Intraluminal dilation of strictures and/or obstructions [e.g., esophagus], radiological supervision and interpretation) to report the procedure.