Gastroenterology Coding Alert

Question: Which CPT code should I assign for a colonic stricture dilatation? The operative notes state, "A CRE colonic balloon dilator was placed across the stricture, and the stricture was dilated from 12 mm to 15."

Gastroenterology Discussion Group

Answer: To perform this procedure, your gastroen-terologist probably performed a colonoscopy to examine the entire colon from the rectum to the cecum. Code 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]) applies to this part of the procedure.

However, no CPT code describes dilation of the colon. Therefore, you should use an unlisted-procedure code. Report 44799 (Unlisted procedure, intestine).

Submit a letter with the claim explaining the procedure and comparing it to a comparable CPT code. Proctosigmoidoscopy with dilation (45303) is similar to the procedure you describe. Both procedures require the physician to use a balloon or other device to dilate an area. Code 45303 refers to a dilation of the rectal stricture, whereas the procedure performed dilated the colonic stricture. And, the gastroenterologist examined the entire colon, not just the rectum and sigmoid colon. Therefore, the work involved in the procedure performed is greater than the work required for 45303. Your physician should estimate how much more work she performed.