Gastroenterology Coding Alert

Question: What codes can we use for an ileoscopy through a stoma with balloon dilation?

Robert C. Kapel, M.D.
Danbury, Conn.


Answer: The code to bill the ileoscopy through stoma is 44380 (ileoscopy, through stoma; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]). Although there is no specific CPT code for reporting a balloon dilation in the small bowel and stoma, you can try using 44799 (unlisted procedure, intestine) to report the procedure to both Medicare and commercial insurers. The code 44380 should be listed first on the claim followed by 44799. Some payers may require the use of modifier -51 (multiple procedures) with the code 44799.

Another option for coding the balloon dilation would be to attach the -22 modifier (unusual procedural services) to 44380. You should contact your local Medicare payer or commercial insurer to determine what coding method they prefer.

Regardless of how you handle the coding for the balloon dilation, adequate documentation in the form of an operative report and a separate statement describing the procedure must accompany the claim. The separate statement also should include any and all information that explains why the balloon dilation is above and beyond the usual endoscopic service described in the CPT code.

The balloon dilation claim likely will not be reimbursed the first time it is billed to a local payer and will have to be appealed. Unfortunately, this is one of many instances in gastroenterology when the CPT codes have not kept up with medical technology.