Wiki Endoscopy with Dilation

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apmc

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I can't seem to find any info on this situation and hope someone out there can help me. Doc does an endoscopy to duodenum. Found an obstruction in gastroesophageal junction and did a Maloney dilation.
The doc found a similar question in a Gastro coding newsletter that states we should bill a 43235 and also a 43450 because this does not fall into a CCI bundle. It goes on to say we were should NOT append modifier -59 for the dilation.
My question is this:
Is the only reason why these 2 codes can be billed because there is no specific definition under the endoscopic codes related to the MALONEY dilation? As in- if the doc had done a balloon dilation we would code as only 43249 but because it was Maloney it should have the two separate codes?
Is it related to the fact that the endo was diagnostic?
I am confused and would like to see if I can get any feedback on this issue.
Thanks in advance to your comments.
 
Susan: Code 43450 is in a different section of CPT than the endoscopy codes including 43235. It is in the manipulation section. Maloney dilations can be done without endoscopy. Other dilations done with endoscopy (and in the "family" of EGD codes) include 43248 when an EGD is performed followed by insertion of a guidewire with the dilator passed over the wire. Another dilation done with endoscopy is 43249 when EGD is performed and a balloon dilator is passed through the scope to accomplish the dilation.
 
Hi Jenny,
Thanks so much for the response. I am still a little confused though. Are you saying we should be using only the code within the endoscopy family? And if so, which would I use for the Maloney bougie?
Thanks again!
 
Susan, If your physician did an EGD and then dilated with Maloney dilators, you would code the EGD (43235) and code the dilation (43450) as you stated in your original post. The point is, this procedure requires two CPT codes with no modifier necessary. The other dilations I mentioned require one code. Those dilations include the EGD. Look at the description in CPT for 43248 and 43249 and you'll see they state EGD...with insertion of guide wire followed by dilation of esophagus over guide wire for 43248; and EGD...with balloon dilation of esophagus...for 43249. 43450 states, "dilation of esophagus..." and does not include endoscopy.
 
Jennyor anyone-
Why would you not use modifier 51 appended on 43450 when billed with 43235? It's not an add-on-can you help?

Leslie, CPC, CPC-P, CPMA
 
You should use a 51 modifier for some insurances, if you code for a physician(s). If you are coding/billing for a facility that modifier is not needed. For the physicians I code for anytime I use more than one cpt code I put the 51 modifier. It may not always be needed for every carrier, but I haven't seen any denials due that modifier when billing for a physician.

Bob
 
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