Gastroenterology Coding Alert

Question:  A patient recently visited our office with a complaint of dysphagia. Our GI performed an EGD with bougie dilation for strictures found during the procedure. How should I report the procedure? What is a bougie dilation? Also, there was a biopsy taken during the EGD. Is it correct to bill the biopsy along with the bougie dilation. 

South Carolina Subscriber

Answer: The code for the esophagogastroduodenoscopy (EGD) will depend on the site of stricture noted in the physician’s documentation and the specific dilation device. A “bougie” is a flexible rubber or plastic tube that comes in varying shapes and progressive diameters. The flexible device can be passed into the esophagus or stomach over a guidewire (the “Savory” or “American” dilator type) or can be passed directly (“Maloney” or “Hurst” type). Another type of dilation can be performed with a balloon rather than a bougie. If the stricture was found in the esophageal region, and your physician used a Maloney bougie then you will report code 43450 (Dilation of esophagus, by unguided sound or bougie, single or multiple passes). In the cases where strictures are in gastric/duodenal region, you should opt for code 43245 (Esophagogastroduodenoscopy, flexible, transoral; with dilation of gastric/duodenal stricture(s) [eg, balloon, bougie]). If your physician used fluoroscopy for radiological supervision and interpretation, use 74360 (Intraluminal dilation of strictures and/or obstructions [eg, esophagus], radiological supervision and interpretation).

Esophageal dilatation is a technique that physicians use to stretch or open a blocked portion of the esophagus. Strictures may occur throughout the GI tract and can occur from a variety of benign and malignant reasons. After the patient is appropriately prepped and anesthetized, the provider passes the bougie into the esophagus. This may be repeated several times, gradually increasing the diameter of the instrument each time until the provider believes that he has achieved sufficient or maximum dilation of the esophagus. The provider may use a lighted endoscope before and after the dilations to examine the stricture and check for any potential injury but performs the dilations without the aid of an endoscope. At the end of the procedure, the provider removes all instruments. Sometimes, a physician will use fluoroscopy to aid the procedure.

If your physician performed a biopsy, you can report the same with CPT® code 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple) as there is no restriction for reporting 43239 with bougie dilation procedure.