Gastroenterology Coding Alert

Question: My physician’s documentation states that he performed esophagoscopy with Botox and Savary dilation. Can you help me code this procedure? Can you shed some light on the Savary dilation procedure?

New Mexico Subscriber

Answer: For the Botox injections, you should choose service code 43201 (Esophagoscopy, flexible, transoral; with directed submucosal injection[s], any substance). Check with your local carrier for exact accepted codes. Some carriers may also accept code 96379 (Unlisted therapeutic, prophylactic, or diagnostic intravenous or intra-arterial injection or infusion).

Don’t forget that payers will reimburse for only one injection code to treat achalasia, regardless of the number of injections the gastroenterologist administers. For example, reporting 43201 x 3 to represent three injections of Botox could get you a denial.

A Savary dilator is the brand name for a dilator that can be passed over a guide wire placed during EGDs, especially when strictures become too tight for the scope to pass the narrowed region. The physician initially performs an endoscopy to evaluate the anatomy, and passes a guidewire into the stomach past the obstruction in the esophagus. Then, the scope is removed leaving the guidewire in place allowing the physician to introduce the Bougies (dilators), over the guidewire, in sequentially increasing sizes. Savary or Savary-Gilliard dilators are the most commonly used bougie over guidewire dilators. Check the operative notes and verify whether the gastroenterologist used a rigid or flexible scope to examine the esophagus and place the guidewire. For the Savary dilation used by the physician, you should report 43226 (Esophagoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator[s] over guide wire). You should report 43196 (Esophagoscopy, rigid, transoral; with insertion of guide wire followed by dilation over guide wire) for a rigid esophagoscopy.

Use of the Botox injection and Savary dilator is a common recourse used by gastroenterologists to treat a condition known as achalasia. Achalasia is an affliction of the esophagus where the lower esophageal sphincter (a ring of muscle situated between the lower esophagus and the stomach) does not open and let food pass into the stomach. Most patients also have diminished contractile motility throughout the length of the esophagus which contributes the poor movement of food into the stomach.

Note: Though it is rare, the gastroenterologist may sometimes send the dilator over a guide wire without using an endoscope but rather a fluoroscope to insert the wire. If this occurs, report 43453 (Dilation of esophagus, over guide wire).