General Surgery Coding Alert

Question: What are the proper codes for the following procedures:

EGD with biopsies of the proximal stricture, highly suspicious for malignancy

Balloon dilatation of 10-12 cm with good proximal opening to allow for the deployment of stent

Esophageal stent, 12 cm, placed, extending from 25-26 cm all of the way distally.

The procedure notes read as follows:

The physician advances a scope into the proximal esophagus. At about 30 cm, a very tight stricture blocked the scope from passing. Multiple biopsies of the stricture site were performed, and it was decided to proceed with a balloon dilatation to at least open up the proximal part. After the balloon dilatation was carried out, a microinvasive Nitrol 12-cm esophageal stent was deployed over a guide wire. The proximal part of the stent was around 25 cm and the distal probably was around 38-40 cm. After the stent was applied, a lot of reflex and a gush of stomach contents were noted, suggesting a good opening of the strictured area.

North Carolina Subscriber

Answer: The correct codes for the operative session described would be:

43202 esophagoscopy, rigid or flexible; with biopsy, single or multiple

43219 ... with insertion of plastic tube or stent

43220 ... with balloon dilation [less than 30 mm diameter].

Although listed as such by the surgeon, an esophagogastroduodenoscopy (EGD) was not performed because the scope never passed the pyloric valve, notes Elaine Elliott, CPC, a general surgery coding and reimbursement specialist in Jensen Beach, Fla.

When billing the carrier for this session, modifier -51 (multiple procedures) should not be used because the multiple endoscopy rule applies. According to the rule, the highest-valued of the three procedures (in this case, the esophagoscopy with stent insertion, 43219; 4.85 relative value units [RVUs]) will be paid at 100 percent. The carrier will subtract the value of the base code for this endoscopic group (43200, esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]; 3.06 RVUs) from both 43202 (3.42 RVUs) and 43220 (3.67 RVUs). In other words, 43202 will be pay 0.36 RVUs (the difference between 43202 and 43200), and 43220 will reimburse 0.61 RVUs, for a total payment of 5.82 RVUs.