Gastroenterology Coding Alert

Question: Our gastroenterologist performed an endoscopy to the duodenum. He found a mild Schatzki ring (acquired) in the gastroesophageal junction. He dilated it with a 50Fr Maloney dilator. Do I code the dilation separate from the EGD?

New Mexico Subscriber

Answer: Use 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) for the endoscopy. Use 43450 (Dilation of esophagus, by unguided sound or bougie, single or multiple passes) for the Maloney dilation.

Don't append modifier 59 (Distinct procedural service) for the dilation; the Correct Coding Initiative (CCI) does not bundle 43450 into 43235. If the gastroenterologist performed the dilation with a guide wire, use 43248 (... with insertion of guide wire followed by dilation of esophagus over guide wire). If the doctor performed a balloon dilation, use 43249 (... with balloon dilation of esophagus [less than 30-mm diameter]).