General Surgery Coding Alert

Question: Our surgeon performed an EGD on a patient with achalasia, and the notes stated “a diagnostic EGD was used to visualize, balloon was inserted with fluoroscope to visualize the inflation of the balloon and dilation was achieved with a balloon > 30 mm.” How should I report the EGD? In another case, the physician used balloon dilation for removal of foreign bodies. What are the procedure codes for this?

California Subscriber

Answer: When surgeons resort to dilation by balloon greater than 30 mm diameter during an esophagogastroduodenoscopy (EGD) for treatment of achalasia, it usually means the muscle fibers of the lower esophageal sphincter are broken and not just stretched.

Because there is a risk that the esophagus could be perforated during the dilation, it is likely that the surgeon will use both an endoscope and fluoroscope during this procedure. Go through the notes to check the extent of the scope used.

For a confirmed EGD, you should report 43233 (Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed)). Otherwise, for an esophagoscopy, you should report 43214 (Esophagoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed)).

You should use the appropriate dilation code first to report the inflation and manipulation of the balloon dilator, because it is the procedure with the higher RVU. Reimbursement for the manipulation with balloon should be 100 percent of the standard fee.

Do not report code 74360 (Intraluminal dilation of strictures and/or obstructions (eg, esophagus), radiological supervision and interpretation) for the fluoroscopy because the procedure description for code 43233 includes the fluoroscopy.

For the second case of dilations reported with removal of foreign bodies lodged in the esophagus, the code choice depends on the extent of the procedure. Either use two esophagoscopy codes, one for balloon dilation and the second for foreign body removal, or two EGD codes for balloon dilation and for foreign body removal. The code pairs are not bundled, so you don’t need a modifier. That means you’ll get paid for the second code following multiple procedure rules within the same family of codes. For instance, the two EGD codes you can use are 43233 for the balloon dilation and 43247 (Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body(s)) for the foreign body removal.