Gastroenterology Coding Alert

Question: We performed an upper endoscopy of the stomach, esophagus, and duodenum with biopsies of the esophagus, stomach and duodenum and balloon dilatation of the distal esophagus stricture. Which codes should we report, and is a modifier necessary? The operative technique reads as follows:

“A timeout was done. The patient was given IV sedation. The gastroscope was used to visualize the esophagus, stomach, and duodenum. The patient did have a distal esophageal stricture which was balloon dilated for 1 minute 30 seconds at level 3 atmospheres. The endoscope was not able to be passed into the stomach until this balloon dilatation occurred. There did not appear to be major trauma to the wall of the esophagus. The biopsy was taken of the esophagus, stomach, and duodenum. There was no ulceration or other disease. The scope was retroflexed in the stomach and withdrawn after being past to the third portion of the duodenum.”

Codify Subscriber

Answer: In this situation, the correct codes are 43249 (Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter)) and 43239 (… with biopsy, single or multiple). Append modifier 59 (Distinct procedural service) to 43239.

If, however, the scenario was that the only biopsy was done at the stricture site, National Correct Coding Initiative (NCCI) edits would preclude billing biopsy and dilation of same site/lesion. So, it is wise to put some comment in field 19 on the claim stating, “biopsy of different sites than dilation,” since the claim would likely be reviewed and the comment may help prevent delay and request for record.