Gastroenterology Coding Alert

Question: The gastroenterologist saw a patient with a history of gastro­esophageal reflux disease (GERD) who presented with a new onset of dysphagia. They performed an upper GI endoscopy and found a benign stricture of the esophagus, which the doctor dilated during the procedure. What should I put on the claim?

New Jersey Subscriber

Answer: A good way to think about scenarios like this is to consider the reason for the encounter. In this case, the dilation procedure is related to the esophageal stricture. So the encounter is to treat the dysphagia, not GERD, which is related to the dysphagia but documented as history. To correctly code the encounter, you first need to code the reason for the encounter. In this case, that’s the new onset of dysphagia, coded as R13.10 (Dysphagia, unspecified). Next, you want to code the history of GERD by using K21.9 (Gastro-esophageal reflux disease without esophagitis). Then, you would code the finding of the benign esophageal stricture. This is coded as K22.2 (Esophageal obstruction). Finally, code the procedure performed. The dilation of the esophageal stricture, if performed using a balloon dilator, is coded as 43220 (Esophagoscopy, flexible, transoral; with transendoscopic balloon dilation (less than 30 mm diameter)). If the procedure is performed using esophagogastroduodenoscopy (EGD), you’ll use the counterpart code 43249 (Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter)).