Gastroenterology Coding Alert

Because there are many different ways that a gastroenterologist can dilate an esophagus, theres an often confusing array of dilation codes from which to chose. The type of dilator used and whether an endoscope and/or a fluoroscope were employed during the procedure will determine which CPT codes should be reported. In addition, not all manipulation codes used to report a dilation include an endoscopy in their description, and that procedure may have to be reported separately if it is performed by the gastroenterologist.

Esophageal dilations are performed when there is a stricture or abnormal narrowing of the esophagus, states Jane Allaire, RN, CGRN, a nurse endoscopist at the National Naval Medical Center in Bethesda, Md. The stricture could be due to a variety of causes, including a tumor, prolonged use of a nasogastric tube or complications from gastrointestinal reflux disease.

Five Categories for Classifying Dilations

Although dilation procedures will vary due to the nature, size and location of the stricture, the most frequent methods for reporting esophageal dilations can be summarized in the following five categories:

1. Dilation by balloon of less than 30 mm diameter: The gastroenterologist performs an endoscopy to visualize the esophagus, and then a deflated balloon is placed through the scope and across the stricture, explains Allaire. The endoscope remains in place while the balloon is inflated to a diameter of less than 30 mm.

Code 43220 (esophagoscopy; with balloon dilation less than 30 mm diameter) or 43249 (upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with balloon dilation of the esophagus less than 30 mm diameter) should be used to report this particular procedure, says Pat Stout, CMC, CPC, an independent gastroenterology coding consultant in Knoxville, Tenn.

Code 43249 includes an EGD (esophagogastroduodenoscopy) in its description, which means that it should be used when the endoscope passes the pyloric channel and extends down into either the duodenum and/or jejunum. Code 43220 includes an esophagoscopy in its description and is used when the endoscope passes the diaphragm but not the pyloric channel. The gastroenterologist may pass the endoscope all the way into the stomach, notes Stout, and then dilate the upper esophagus before removing the scope. In that case, code 43249 should be reported.

The standard practice is to code for the endoscopic family in which the gastroenterologist was able to advance the scope, she explains. If the scope was extended into the stomach and into either the duodenum or jejunum for reasons of medical necessity, then it is appropriate to report the work done as an EGD.

It also is not uncommon for a gastroenterologist to perform an EGD the first time a patient is dilated, but perform an esophagoscopy during dilations that may occur a few months later. The gastroenterologist in that situation would report 43249 for the initial session and 43220 for the subsequent dilations.

2. Dilation over endoscopically placed guide wire: The gastroenterologist will perform an endoscopy to visualize the stricture and to pass a guide wire into the stomach. The endoscope is then removed from the patient, but the guide wire remains in place. A dilator (or series of dilators) with a lumen in the middle is threaded onto the guide wire and advanced until the dilator reaches the stricture. The dilators used in this procedure also may be referred to as American or Savary-type dilators, reports an article in the spring 1994 CPT Assistant.

Code 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) is used to report both the insertion of the guide wire and the subsequent passage of the dilator when done during an EGD. Code 43226 (esophagoscopy; with insertion of guide wire followed by dilation over guide wire) is used when the guided dilation is done during an esophagoscopy.

As with balloon dilations, if a gastroenterologist extends the endoscope into the stomach and returns to perform a dilation in the esophagus, 43248 can be reported. Or as with the balloon dilation, the gastroenterologist may perform an EGD the first time a patient is dilated, but perform only an esophagoscopy during dilations that may occur a few months later. In that case, the gastroenterologist would report 43248 for the initial session and 43226 for the subsequent dilations.

3. Unguided dilator, endoscope and/or fluoroscope optional: Some dilators can be inserted into the patient without the use of an endoscope or guide wire, explains Allaire. An endoscope may be used to visualize the stricture, but the scope will be removed from the patient before the dilation is done. The gastroenterologist frequently may use a fluoroscope here to guide the placement of the dilator. According to the spring 1994 CPT Assistant , Hurst and Maloney-type dilators are used during this procedure.

Code 43450 (dilation of esophagus, by unguided sound or bougie, single or multiple passes) is used to report the non-endoscopic insertion and manipulation of the dilator, says Stout. If an endoscopy is performed before the dilation, that should be reported separately.

If an EGD with biopsy (43239) is performed before the insertion of a Maloney dilator, a gastroenterologist submitting a claim to Medicare or a private payer that follows Medicare rules should report 43239 first because it has the higher relative value unit (RVU) and expect reimbursement to be 100 percent of the standard fee. Code 43450 with modifier -51 (multiple procedures) attached should be reported next. Reimbursement will be 50 percent of the standard fee because Medicares multiple procedure rules apply.

The gastroenterologist also can report the use of the fluoroscope separately if he or she does the supervision and interpretation. If a gastroenterologist uses a fluoroscope in the previously mentioned example, 74360 (intraluminal dilation of strictures and/or obstructions [e.g., esophagus] radiological supervision and interpretation) with modifier -51 attached also should be reported. Reimbursement for the fluoroscope will be 50 percent of the standard fee because the Medicare multiple procedures rules apply.

Allaire adds that unguided dilations can be performed without the aid of either an endoscope or fluoroscope, especially when done during a subsequent dilation session. Then, only manipulation code 43450 should be reported.

4. Dilation over a guide wire, no endoscope: Although not frequently used, code 43453 (dilation of esophagus, over guide wire) is for cases in which a dilator is inserted over a guide wire that was not placed endoscopically, Stout says.

In this situation, the gastroenterologist may use a fluoroscope to visualize the placement of the guide wire. Code 74360 should be used to report the supervision of the fluoroscopy, and reimbursement should be 100 percent of the standard fee because this is the higher-valued procedure. The dilation code 43453 should have modifier
-51 attached, and reimbursement should be 50 percent of the standard fee because the multiple procedures rules apply.

5. Dilation by balloon greater than 30 mm diameter for treatment of achalasia: When esophageal dilation is being performed to treat achalasia, the muscle fibers of the lower esophageal sphincter are broken and not just stretched with a balloon dilator that is greater than 30 mm in diameter.

Because there is a risk that the esophagus could be perforated during the dilation, it is likely that an endoscope and fluoroscope both will be used during this procedure, explains Allaire. A gastroenterologist might perform, for example, a diagnostic EGD (43235) to visualize the esophagus and insert the balloon, and use a fluoroscope to visualize the inflation of the balloon.

In this situation, 43458 (dilation of esophagus with balloon [30 mm diameter or larger] for achalasia) should be used first to report the inflation and manipulation of the balloon dilator because it is the procedure with the higher RVU. Reimbursement for the manipulation with balloon should be 100 percent of the standard fee. Code 43235 with modifier -51 attached should be used to report the EGD; reimbursement should be 50 percent of the standard fee because the multiple procedures rules apply. Code 74360 with modifier -51 attached should be used to report the fluoroscopy; reimbursement should be 50 percent of the standard fee because the multiple procedures rules apply.

Dilations Reported With Removal of Foreign Body

Balloon dilation also can be used to remove foreign bodies lodged in the esophagus. But a note in the CPT manual at the end of the esophagus-manipulation subsection states that 43215 (esophagoscopy, rigid or flexible; with removal of foreign body), 43247 (upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of foreign body) or 74235 (removal of foreign body[s], esophageal, with use of balloon catheter, radiological supervision and interpretation) should be used to report these procedures.

Finally, the endoscope itself sometimes may be used to dilate a stricture, with no other type of dilator used during that session. Because there is no code for dilation via an endoscope, reports the January 1997 CPT Assistant, only the endoscopy can be reported.

Not all Medicare carriers or private insurance companies require the use of modifier -51 when reporting multiple procedures. Some payers require the use of a different modifier, and others require no modifier at all. Gastroenterologists should check with their local payers for specific coding instructions. For more on Medicares multiple procedures rules, please see Multiple Procedures: Increase Reimbursement With Correct Modifiers and ICD-9 Codes in the March 2000 Gastroenterology Coding Alert and Optimize Billing for Three or More Endoscopic Procedures Performed on the Same Day in the May 2000 issue.