Gastroenterology Coding Alert

Question: Our gastroenterologist recently performed an EGD on a patient with achalasia. The notes stated that the GI performed a diagnostic EGD to visualize, balloon was inserted with fluoroscope to visualize the inflation of the balloon and dilation was achieved with a balloon > 30 mm. How should I report the EGD for best reimbursement? In another case, the physician used balloon dilation for removal of foreign bodies. What are the procedure codes for this?

New Jersey Subscriber

Answer: When gastroenterologists resort to dilation by balloon greater than 30 mm diameter during an Esophagogastroduodenoscopy (EGD) for treatment of achalasia, the muscle fibers of the lower esophageal sphincter are broken and not just stretched with a balloon dilator that is greater than 30 mm in diameter.

Because there is a risk that the esophagus could be perforated during the dilation, it is likely that an endoscope and fluoroscope both will be used during this procedure.

Go through the notes to check the extent of the scope used by the GI. For a confirmed EGD, you should report code 43233 (Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon [30 mm diameter or larger] [includes fluoroscopic guidance, when performed]). Otherwise, for an esophagoscopy, you should report code 43214 (Esophagoscopy, flexible, transoral; with dilation of esophagus with balloon [30 mm diameter or larger] [includes fluoroscopic guidance, when performed]). These dilation codes should be used first to report the inflation and manipulation of the balloon dilator because it is the procedure with the higher RVU. Reimbursement for the manipulation with balloon should be 100 percent of the standard fee. The current national non-facility reimbursement for 43233 is appx. $248.30 (total RVU 6.91 multiplied with 2015 conversion factor 35.9335).

Do not report code 74360 (Intraluminal dilation of strictures and/or obstructions [eg, esophagus], radiological supervision and interpretation) for the fluoroscopy as it is included in the procedure description for code 43233.

For the second case of dilations reported with removal of foreign bodies lodged in the esophagus, you should either use two esophagoscopy codes, one for balloon dilation and the second for foreign body removal. Otherwise, depending on the exact procedure, you should use the two EGD codes for balloon dilation and for foreign body removal. The code pairs are not bundled so a modifier is not needed. Therefore, the second code will be paid following multiple procedure rules within the same family of codes. For instance, the two EGD codes you can use are 43233 for the balloon dilation and code 43247 (Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body[s]) for the foreign body removal in an EGD.