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.

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], radiological supervision and interpretation) with modifier -51 attached. Reimbursement will be 50 percent of the standard fee here, also.

Gastroenterologists also use bougies with guidewires. For this procedure the physician performs an endoscopy, places the guidewire through the endoscope, and removes the endoscope leaving the wire in place. Then, he guides the bougie along the wire, which he removes when the procedure is complete. A physician performs this type of dilation when the strictures are tight or irregularly shaped, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the CPT advisory panel.

You need to be able to recognize this endoscopic procedure by the use of the brand names "Savary" or "American," which may appear in the doctor's notes, he says.

When you identify this type of procedure, you should use 43248 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with insertion of guidewire followed by dilation of esophagus over guidewire) or 43226 (Esophagoscopy, rigid or flexible; with insertion of guidewire followed by dilation over guidewire).

In rare cases, the physician may insert a dilator over a guidewire without using an endoscope. The appropriate code for this is 43453 (Dilation of esophagus, over guidewire). Physicians use fluoroscopes with this procedure to visualize the placement of the guidewire. You can report this service with 74360.

Another common type of dilation involves a balloon dilator, which is inserted with the aid of an endoscopy, Barron says. When the physician's notes say that the physician placed a deflated balloon dilator through the endoscope and gradually inflated the dilator to open the stricture, look to code 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]) or 43220 (Esophagoscopy, rigid or flexible; with balloon dilation [less than 30 mm diameter]). "Size matters with balloon dilators," Barron says. According to Weinstein, balloon dilators for esophageal strictures come in a variety of styles and sizes ranging up to about 20 mm.

You should report these dilations using 43249. Use this code only when the endoscope passes the esophageal stricture and enters the stomach and duodenum, Weinstein says.

If the endoscopic balloon dilation does not allow the scope to pass into the stomach, you should use 43220. When the physician passes the endoscope into the stomach and then dilates the upper esophagus before removing the scope, you can report 43249.

The above-mentioned dilators are not large enough to treat some disorders. For example, achalasia is a condition marked by spasm and lack of relaxation of the lower esophageal sphincter (LES) muscle. Gastroenterologists use a larger, balloon-type dilator to treat this problem. Upon gradual expansion, the dilator eventually ruptures the muscle.

You report this procedure with 43458 (Dilation of esophagus with balloon [30 mm diameter or larger] for achalasia). Fluoroscopy often accompanies this dilation procedure. You can report 74360 (Intraluminal dilation of strictures and/or obstructions [e.g., esophagus], radiological supervision and interpretation).

Many doctors perform EGDs (43235) to visualize the esophagus and insert the balloon. You should report this procedure separately. Reimbursement will follow Medicare's multiple-procedure rule, in which each subsequent procedure is reimbursed 50 percent of the standard fee. Code the following: