Gastroenterology Coding Alert

Question: Which CPT^® code applies in this situation: “Scope passed up to middle esophagus, no stricture seen. Wire confirmed in the stomach and CRE balloon used to dilate up to 9mm.”? Since a guide wire was used, should we use 43226 or as a balloon was used, should we use 43220?

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Answer: When your gastroenterologist performs dilation, you will first have to consider the type of dilator that the physician used and also whether they used endoscopy and/or fluoroscopy to perform the procedure. You will also have to examine the extent to which the scope was introduced in the gastrointestinal tract.

In your case scenario, the gastroenterologist used a balloon to dilate the esophagus. Therefore, the most accurate code is 43220 (Esophagoscopy, flexible, transoral; with transendoscopic balloon dilation (less than 30 mm diameter)). But again, you will have to ensure that your gastroenterologist did not advance the scope to view areas of the stomach, duodenum, and/or the jejunum. If the scope was extended to view these areas, you will have to use CPT^® code 43249 (Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter)) to report the procedure.

Because the physician used a guide wire, evaluate whether to use 43226 (Esophagoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) over guide wire) or 43220. You’ll need to determine why the guide wire was used and if it was employed to dilate the esophagus.

You’ll use 43226 only if your gastroenterologist used the guide wire with a bougie system that incorporates the guide wire to dilate the esophagus. In your case scenario, your gastroenterologist used the guide wire to guide the placement of the balloon catheter for the dilation. Therefore, you cannot use 43226 in this case scenario.