Gastroenterology Coding Alert

Question: My gastroenterologist used an esophageal dilation to treat achalasia (530.0) by breaking the lower esophageal sphincter muscle fibers with a balloon dilator larger than 30 mm in diameter. Which codes should I use to report this procedure?

Oregon Subscriber

Answer: You should report 43458 (Dilation of esophagus with balloon [30 mm diameter or larger] for achalasia). Because there's a definite risk of perforation with this procedure, your physician likely used an endoscope to visualize the esophagus and insert the balloon, and fluoroscopy to watch the balloon inflation. If this is the case, you can report the endoscopy and fluoroscopy separately from 43458.

For example, you may also submit 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]) and 74360-26 (Intraluminal dilation of strictures and/or obstructions [eg, esophagus], radiological supervision and interpretation) along with the dilation code.