Gastroenterology Coding Alert

You may report fluoroscopic guidance in many cases

When reporting upper GI dilation procedures, you won't always find the code you need in the -digestive system, manipulation- subsection of CPT. 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 gastroenterologist 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, 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 shape of the bougie). If you encounter any of these terms, you should probably use 43450 (Dilation of esophagus, by unguided sound or bougie, single or multiple passes).

Achalasia dx provides another hint: Achalasia causes spasm and lack of relaxation of the lower esophageal sphincter (LES) muscle. Therefore, gastroenter-ologists must often use a larger, balloon-type dilator to treat this problem. You can report dilations of this type (without an EGD) using 43458 (Dilation of esophagus with balloon [30 mm diameter or larger] for achalasia). Watch for Guidewire and Ballon/Dilator Options 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), says Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Lawrenceville, Ga. More often, however, the gastroenterologist 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 -Pustow dilator- or -Pustow rod,- you can be fairly sure that 43453 is the correct code.

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 ballon or dilator, retrograde). 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 gastroenterologist performs an endoscopy for visualization or other purposes (such as biopsy) prior to dilation using a bougie, you may report the scope separately while still calling on 43450-43458 to describe the dilation itself, Pfaff says.

-Most frequently, the physician will perform a diagnostic EGD to evaluate the GI tract to the duodenum,- Pfaff says. -After assessing the entire upper GI tract, the physician will remove the scope.-

Example: The physician performs a diagnostic EGD (43235, Upper gastrointestinal [...]