Gastroenterology Coding Alert

You're probably tired of staring at your physician's notes for hours trying to decipher terms such as "Maloney," "Hurst" and "Savary," so you need to broaden your dilation coding lingo in order to receive optimal reimbursement for the procedures your gastroenterologist performs.

To determine whether you need to code a 43450, 43249 or 43458, you should understand the difference between these dilation techniques. Gastroenterologists perform dilations when part of the esophagus becomes closed due to certain ailments, such as reflux esophagitis and achalasia. Physicians also use dilators for strictures resulting from scarring following radiation therapy for cancer, caustic ingestions or medications associated with ulcerations, prolonged use of a nasogastric tube, or esophageal spasm disorders. Gastroenterologists must evaluate the stricture and decide between myriad types of dilators. The dilator choice depends on the size and characteristics of the stricture, the physician's judgment, and the patient's history. Nonendoscopic Dilation Requires 4345x Series Gastroenterologists perform some dilations with endoscopes, and others without endoscopic guidance. In  the latter, which are coded as manipulations, the physician may use an endoscope to visualize the stricture but remove it before the dilation is done. Also, he may use a fluoroscope to guide the dilator's placement.

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." The physician may refer to a bougie based on its shape as "Maloney" or "Hurst."

According to Jill Barron, coding specialist for Gastroenterology Associates of Cleveland, physicians use bougie dilators when the stricture type, site and size are known 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 code 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, Barron says. For example, the physician performs an EGD with biopsy (43239) before the insertion of a Maloney dilator. Report 43239 first because it has a higher RVU, and expect 100 percent reimbursement from Medicare, Barron says. Code 43450 with modifier -51 (Multiple procedures) appended and expect 50 percent of the standard fee if you follow Medicare's multiple-procedure rules.

You can code for fluoroscopic guidance when the physician uses a fluoroscope during the procedure. For the above example, you should report 74360 (Intraluminal dilation of strictures and/or obstructions [e.g., esophagus], [...]