General Surgery Coding Alert

Question: How should we code the following esophageal dilation case that includes both a balloon dilation and a guidewire? “Scope passed to middle esophagus; wire advanced to stomach; CRE balloon dilation up to 8 mm.”

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Answer: The best choice for this case is 43220 (Esophagoscopy, flexible, transoral; with transendoscopic balloon dilation (less than 30 mm diameter)).

The key components for selecting an esophageal dilation code are the type of dilator and the extent of scope introduction into gastrointestinal tract.

The documentation indicates that the surgeon did not advance the scope to the stomach, so that would rule out 43249 (Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter)).

Although the report mentions a guidewire, there’s no indication that the wire was used with a bougie system to accomplish the dilation. That means you should rule out 43226 (Esophagoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) over guide wire).

In fact, the dilation was accomplished by balloon, and the surgeon used a CRE wire, which is typically part of a balloon dilation catheter system, indicating code 43220.