Gastroenterology Coding Alert

Question: The provider performed EGD, and identified achalasia. He then performed dilation using a 20mm balloon dilation and injected 100 units of Botox. Can I use modifier 59 along with 43236, since it’s the same site as 43249? Or should I report only 43249?

Maine Subscriber

Answer: An esophagogastroduodenoscopy is a procedure to view the esophagus, stomach, and duodenum by means of a flexible endoscope through the mouth. The provider performs esophageal dilation using a balloon (less than 30 mm) during this procedure.

In procedure code 43249 (Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus [less than 30 mm diameter]), the provider performs esophageal dilation using a balloon (less than 30 mm), but no injection is bundled with the procedure.

In the procedure 43236 (Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection[s], any substance), the provider performs one or more submucosal injections, so injection is included in the procedure itself, but the dilation is not performed. You do not need to append the modifier 59 (Distinct procedural service) with this code.

In this case you may report 43249 along with 43236.