Gastroenterology Coding Alert

Question: Our gastroenterologist performed esophageal dilation on a patient with achalasia. A balloon with a diameter of 30 mm was used to perform the dilation, but the operative note states that the balloon was only inflated to 20 mm. Can we still bill 43458? Also, the gastroenterologist performed an upper gastrointestinal endoscopy (43235). Can we bill separately for this?

Tennessee Subscriber

Answer: You can bill 43458 (dilation of esophagus with balloon [30 mm diameter or larger] for achalasia) even though the gastroenterologist did not fully inflate the balloon dilator to 30 mm, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the CPT Advisory Panel. The purpose of esophageal dilation is to stretch an esophagus that has been narrowed by a stricture. When dilation is performed to treat achalasia, the muscle fibers of the lower esophageal sphincter are broken, not just stretched, with a larger balloon dilator that can be inflated to at least 30 mm in diameter.

These large balloon dilators are now graduated, with markings that indicate to the gastroenterologist when the balloon has been inflated to 20, 25 and 30 mm. A gastroenterologist may choose to only inflate the balloon to 20 mm, perhaps to avoid perforating the esophagus and because the 20-mm dilation was successful, Weinstein says. But 20 mm is still a large dilation and very risky. The gastroenterologist is justified in receiving the slightly higher reimbursement that is paid with 43458.

You may also bill separately for the endoscopy. Because 43458 has a transitioned facility relative value unit (RVU) of 4.57 and 43235 has a comparable RVU of 4.11, 43458 should be reported first. Reimbursement for this procedure should be 100 percent of the standard fee, according to the multiple procedures rule. (They do not have the same endoscopic base code, so the multiple endoscopies rule does not apply.)

Code 43235 should be reimbursed at 50 percent of the standard fee. Your payer may require you to attach modifier -51 to this code to indicate multiple procedures were performed.

Because this is a relatively risky procedure, gastroenterologist may use fluoroscopy instead of or in addition to the endoscopy, and that service may also be billed separately. Code 74360 (intraluminal dilation of strictures and/or obstructions [e.g., esophagus], radiological supervision and interpretation) should be used to report this service. Again, the multiple procedures rule applies.

It is important to use diagnosis code 530.0 (achalasia) when reporting these services. If you use that diagnosis, you should be reimbursed - regardless of how much the dilator was inflated, Weinstein says.