Gastroenterology Coding Alert

You may report fluoroscopic guidance in many cases

When reporting upper GI dilation procedures, you won't always find the code you need in the -digestive system, manipulation- subsection of CPT. In some cases, you will instead choose an endoscopic procedure code. And, in other cases, you may report a scope and a manipulation.

No Scope Means Manipulation Only

If the gastroenterologist does not use a scope during the upper GI dilation, you should report a manipulation code (43450-43458) only, says Margie Pfaff, CPC, corporate compliance analyst for Wisconsin's Medical Associates Health Centers. To determine which of these codes is appropriate to the circumstances, carefully check the physician's documentation.

Look for key terms: When reviewing the physician's notes, look for the descriptors -bougie- (which is a type of flexible dilator), and -Maloney- or -Hurst- (which refer to the shape of the bougie). If you encounter any of these terms, you should probably use 43450 (Dilation of esophagus, by unguided sound or bougie, single or multiple passes).

Achalasia dx provides another hint: Achalasia causes spasm and lack of relaxation of the lower esophageal sphincter (LES) muscle. Therefore, gastroenter-ologists must often use a larger, balloon-type dilator to treat this problem. You can report dilations of this type (without an EGD) using 43458 (Dilation of esophagus with balloon [30 mm diameter or larger] for achalasia).

Watch for Guidewire and Ballon/Dilator Options

In the rare case when the physician inserts a dilator over a guidewire without using a scope, you should report 43453 (Dilation of esophagus, over guidewire), says Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Lawrenceville, Ga. More often, however, the gastroenterologist will use an endoscope to place the guidewire, which calls for different coding (see -Turn to 43226, 43248 for Guidewires,- below).

Key term: When you see the terms -Pustow dilator- or -Pustow rod,- you can be fairly sure that 43453 is the correct code.

For the rare transgastric intraoperative retrograde (reverse direction) dilation using a balloon or dilator without a scope, you should apply 43456 (Dilation of esophagus, by ballon or dilator, retrograde). Most often a general surgeon would perform this procedure. For endoscopic balloon dilations, your code choice will differ (see -Balloon Dilator Calls for 43220 or 43249,- below).

Report Scope for Visualization Separately

If the gastroenterologist performs an endoscopy for visualization or other purposes (such as biopsy) prior to dilation using a bougie, you may report the scope separately while still calling on 43450-43458 to describe the dilation itself, Pfaff says.

-Most frequently, the physician will perform a diagnostic EGD to evaluate the GI tract to the duodenum,- Pfaff says. -After assessing the entire upper GI tract, the physician will remove the scope.-

Example: The physician performs a diagnostic EGD (43235, Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) to evaluate the GI tract before insertion of a Maloney dilator. You should report both 43235 for the EGD and 43450 for the dilation.
 
Other options: The gastroenterologist may use a variety of endoscopic procedures, such as esophagoscopy (43200, Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) or simple upper GI endoscopy (43234, Upper gastrointestinal endoscopy, simple primary examination [e.g., with small diameter flexible endoscope] [separate procedure]), for visualization prior to dilation with a bougie. You may report these procedures separately with 43450. Be sure to select the scope code that best describes the visualization procedure supported by the physician's documentation.

Turn to 43226, 43248 for Guidewires

Often, the physician will use a scope to place a guidewire and then insert a dilator along the wire.

If the gastroenterologist visualizes the stomach and duodenum at any point before or after the dilation, report 43248 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with insertion of guidewire followed by dilation of esophagus over guidewire).

If the doctor could not pass the scope beyond the stricture and only visualized the esophagus, report instead 43226 (Esophagoscopy, rigid or flexible; with insertion of guidewire followed by dilation over guidewire).

You cannot report visualization separately with these procedures. Visualization is included with the dilation.

Key terms: For these procedures, the physician's documentation may refer to the brand names -Savary- (which describes the wire) or -American- (which describes the dilator), Pfaff says.

Balloon Dilator Calls for 43220 or 43249

When the gastroenterologist's documentation specifies that he placed a deflated balloon dilator through the endoscope and gradually inflated the dilator to open the stricture, you can choose from either 43249 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with balloon dilation of esophagus [less than 30 mm diameter]) or 43220 (Esophagoscopy, rigid or flexible; with balloon dilation [less than 30 mm diameter]), Parks says.

Report 43249 when the endoscope passes the esophageal stricture and enters the stomach and duodenum.

You should claim 43220 if the endoscopic balloon dilation does not allow the scope to pass into the stomach.

Note: As with 43226 and 43248, you should include visualization as part of the dilation with these procedures.

Bonus Tip: Don't Forget Fluoroscopy

You can report fluoroscopy separately using 74360 (Intraluminal dilation of strictures and/or obstructions [e.g., esophagus], radiological supervision and interpretation) when the physician uses this method to guide placement of a bougie, guidewire or balloon (43450-43458).

Example: The gastroenterologist performs EGD to visualize the upper GI tract prior to inserting a bougie, as in the first example above. In addition, the physician uses fluoroscopy to ensure correct placement of the Maloney dilator. You would report 43235 for the EGD, 43450 for the dilation and 74360 for the fluoroscopic guidance.