Help Please...
documentation clearly states dilation over guidewire (43453)
however there is nothing regarding fluoroscopy being used
i know that fluroscopy is listed in the description of procedure - was unsure if that was necessary to bill.
Procedure Note;
Findings: Esophagus: the proximal and middle part of esophagus was normal. there was a stricture noted in the distal esophagus at the gastroesophageal junction. this appeared to be a peptic stricture. this was dilated over a guide wire at 51 french and 54 french savary dilators. the stomach appeared normal. the duodenum appeared to be normal.
I was going to bill 43235 & 43453 (?)
Please provide thoughts / suggestions
documentation clearly states dilation over guidewire (43453)
however there is nothing regarding fluoroscopy being used
i know that fluroscopy is listed in the description of procedure - was unsure if that was necessary to bill.
Procedure Note;
Findings: Esophagus: the proximal and middle part of esophagus was normal. there was a stricture noted in the distal esophagus at the gastroesophageal junction. this appeared to be a peptic stricture. this was dilated over a guide wire at 51 french and 54 french savary dilators. the stomach appeared normal. the duodenum appeared to be normal.
I was going to bill 43235 & 43453 (?)
Please provide thoughts / suggestions