Gastroenterology Coding Alert

Here's how to break down methods of dilations into five easy categories

Your gastroenterologist can dilate a patient's esophagus in several different ways, making several CPT codes applicable, but pinpointing two vital ingredients will get your esophageal dilation claims paid every time.

To ensure the appropriate choice, focus on:

• the type of dilator the gastroenterologist used
• whether he used an endoscope and/or fluoroscopy.

Did you know? Your gastroenterologist will perform an esophageal dilation to treat a stricture or abnormal narrowing of the esophagus, which could be caused by a variety of conditions, such as a tumor, prolonged nasogastric tube use or complications from gastroesophageal reflux disease (GERD). You can summarize the most frequent methods for reporting esophageal dilations into five categories:

1. Use 43220, 43249 for Dilation by Balloon of < 30-mm Diameter

If your physician's notes include a dilation by balloon of less than 30-mm diameter, you can automatically look to two codes:

• 43220--Esophagoscopy, rigid or flexible; with balloon dilation (less than 30-mm diameter)

• 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).

Example: A gastroenterologist performs an endoscopy to visualize the esophagus and then places a deflated balloon through the scope and across the stricture. The endoscope remains in place while the physician inflates the balloon to a diameter of less than 30 mm. If the gastroenterologist passes the endoscope beyond the diaphragm but not the pyloric channel, you should report 43220. But if the physician does pass the pyloric channel--regardless of where the esophageal stricture is located--use 43249.

Watch out: You cannot report 43249 as well as 43450 (Dilation of esophagus, by unguided sound or bougie, single or multiple passes) without confronting a Correct Coding Initiative edit, says Connie Pitman, a coder at Lubbock Digestive Disease Associates in Lubbock, Texas. This edit carries a "0" modifier indicator, which means you cannot bill the codes together under any circumstances.

2. Dilation Over Placed Guidewire Means 2 Codes

Second, your gastroenterologist may perform an endoscopy to visualize a stricture and to pass a guidewire into the stomach. He then removes the scope, leaving the guidewire in place, and threads the dilator (or a series of them) with a lumen onto the wire and advances it until the dilator reaches the stricture. Your physician may refer to this type of dilator as American or Savary type.

What to do: When your physician performs this type of dilation, you should report 43248 (...with insertion of guidewire followed by dilation of esophagus over guidewire), which covers both the guidewire insertion and the dilation. If the gastroenterologist doesn't pass the endoscope into the stomach to place the guidewire, instead use 43226 (... with insertion of guidewire followed by dilation over guidewire).

3. Don't Overlook Fluoroscopy Option

Your gastroenterologist can insert some dilators into the patient without using an endoscope or guidewire. The physician may use the scope to visualize the stricture but remove it before performing the dilation. Your physician's documentation may refer to Hurst or Maloney-type dilators if he performs this type of procedure.

What to do: You should report 43450 (Dilation of esophagus, by unguided sound or bougie, single or multiple passes) for nonendoscopic dilator insertion and manipulation. And if your physician uses an endoscope before starting the dilation, you would report that separately.

Similarly, if your gastroenterologist uses fluoroscopy and does the supervision and interpretation, you can report that separately with 74360 (Intraluminal dilation of strictures and/or obstructions [e.g., esophagus], radiological supervision and interpretation), according to CPT.

4. Determine Code for Rarely Performed Procedure

Although your gastroenterologist will rarely perform this type of procedure, you should know that you would use 43453 (Dilation of esophagus, over guidewire) when he inserts a dilator over a guidewire without first placing the guidewire with an endoscope. Instead, he may use fluoroscopy to place the guidewire, and you would report this separately with 74360.

5. Achalasia Requires Unique Code: 43458

Your gastroenterologist may use esophageal dilation to treat achalasia (530.0) by breaking the lower esophageal sphincter muscle fibers with a balloon dilator larger than 30 mm in diameter.

What to do: You'll report 43458 (Dilation of esophagus with balloon [30 mm diameter or larger] for achalasia). Because there's a definite risk of perforation with this procedure, your physician will likely use an endoscope to visualize the esophagus and insert the balloon, and fluoroscopy to watch the balloon inflation.

If this is the case, you can report the endoscopy and fluoroscopy separately from 43458. For example, you may also submit 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]) and 74360 along with the dilation code.

Finally, your physician may use the endoscope to dilate an esophageal stricture, using no other type of dilator to achieve the task. In this case, you should report only the endoscopy because CPT doesn't contain a code for dilation via an endoscope.