Gastroenterology Coding Alert

Question: How should I report an endoscopic procedure based on the following op note?

"The patient was placed in the left lateral decubitus position. After adequately sedating the patient, the physician performed esophageal intubation under direct visualization using diagnostic front-view endoscope. The physician advanced the scope all the way to the descending duodenum, and found a benign appearing, most likely reflux induced GE junction stricture with maximum diameter of approximately 12 mm. The stricture corresponds with Z line located at 37 cm from incisors. There was also a 3-cm hiatal hernia. Biopsies from the GE junction stricture were taken for histologic evaluation in bottle #2. Biopsies from normal appearing mucosa and stomach antrum and body were taken to check for H. pylori in bottle #1. A guidewire was introduced into the stomach antrum and the scope was withdrawn. The esophageal stricture was then dilated with American dilators #48 and 51 French dilators. The patient tolerated the procedure well and left the endoscopy suite in satisfactory condition. The patient did not experience any immediate complications."

New Mexico Subscriber

Answer: Here's what you should report on your claim: For the first line, bill 43248 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with insertion of guide wire followed by dilation of esophagus over guide wire) with 530.3 (Stricture and stenosis of esophagus), and any indications or symptoms linked to it.

For the second line, report 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple). Link it to a diagnosis code for the indication/ symptom, and ICD-9 codes 530.3 (Stricture and stenosis of esophagus) and 553.3 (Diaphragmatic hernia without obstruction or gangrene).