Gastroenterology Coding Alert

Question: The patient is admitted for diagnostic EGD (43235).Preoperative diagnosis indicates dysphagia and history of benign esophageal stricture. The gastroenterologist writes in her report, "Found esophageal stricture at 37 cm and scope would not pass. Dilation of distal esophageal with #16.5 and #18 hydrostatic balloon. Then proceeds to stomach and duodenum." She wants to bill 43235 and 43220, but I heard a CCI edit is in place for this combination. Do you have any suggestions on how we can be paid for both services performed?

Minnesota Subscriber

Answer: The appropriate code would be 43249 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with balloon dilation of esophagus [less than 30 mm diameter]).

Background: When the physician's documentation specifies that he placed a deflated balloon dilator through the endoscope and gradually inflated the dilator to open the stricture, you can choose from either 43249 or 43220 (Esophagoscopy, rigid or flexible; with balloon dilation [less than 30-mm diameter]). You should claim 43220 if the endoscopic balloon dilation does not allow the scope to pass into the stomach. On the other hand, report 43249 when the endoscope passes the esophageal stricture and enters the stomach and duodenum. You may see the term TTS balloon or TTS balloon catheter in the procedure report to describe the dilator. TTS stands for through-the-scope.