Gastroenterology Coding Alert

Question: Our physician performed an esophagoscopy on a Medicare patient before the insertion of a Maloney bougie dilator. How should I code this? Is there a different code for guidewire dilation?

North Dakota Subscriber

Answer: No matter how it is coded, Medicare’s multiple-procedure rules will apply and you can expect 100 percent reimbursement for the primary and highest paying procedure. Depending on the extent of esophagoscopy procedure performed by your physician, you can report any of the following:

• 43191 -- Esophagoscopy, rigid, transoral; diagnostic, including collection of specimen(s) by brushing or washing when performed (separate procedure) 

• 43200 -- Esophagoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure).

For the Maloney dilation, you should report code 43450 (Dilation of esophagus, by unguided sound or bougie, single or multiple passes). If the physician uses a fluoroscope during this procedure, you should use code 74360 (Intraluminal dilation of strictures and/or obstructions [e.g., esophagus], radiological supervision and interpretation) with modifier 26 (Professional component) for the physician’s interpretation. You can expect a reimbursement 50 percent of the standard fee here, also.

Sometimes, gastroenterologists need to use guide wires with bougie dilations, usually when strictures either become too tight or take on irregular shapes. When coding this type of procedure, consider the exact sequence of events the physician undertook in placement of the bougie. In such a case, you can use either of the following codes:

• 43196 -- Esophagoscopy, rigid, transoral; with insertion of guide wire followed by dilation over guide wire

• 43226 - Esophagoscopy, rigid or flexible; with insertion of guide wire followed by passage of dilator (s) over guide wire 

• 43248 - Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire

If the physician sends a dilator over a guide wire, you should code 43453 (Dilation of esophagus, over guide wire). For the fluoroscopy, use code 74360 with modifier 26 attached.

Heads up: You can spot endoscopic dilations using a guide wire if you go through the procedure notes with a keen eye. Endoscopic procedures are easy to spot by the use of the words “Savary” or “American,” two common guide-wire dilator brand names. If you find either of these keywords in the doctor’s notes, be on the lookout for a guide-wire dilation.