Radiology Coding Alert

Question: A patient with esophageal reflux was undergoing an MBS study with videoradiography. Documentation shows the patient became so unwell during the procedure that the study was terminated before completion. Which procedure and diagnosis codes should we report?

Arkansas Subscriber

Answer: The appropriate procedure code for this modified barium swallow (MBS) study is 74230 (Swallowing function, with cineradiography/videoradiography). Because the test was terminated in response to concerns for the patient's welfare, you should append modifier 53 (Discontinued procedure) to 74230.

To indicate the diagnosis that prompted the exam, you should choose 530.81 (Esophageal reflux). Your payer also may ask you to include a diagnosis code, such as V64.1 (Surgical or other procedure not carried out because of contraindication) to support the use of modifier 53.