Gastroenterology Coding Alert

When the gastroenterologist performs a bougie dilation of a patient's esophagus to ease an esophageal stricture, be on the lookout for modifier missteps you could make. Put a modifier where you don't need one, and you could lose out on deserved reimbursement. Use this FAQ to hammer down the coding facts and nail each bougie encounter.

When the gastroenterologist performs bougie dilation for one of his patients, you'll code the service with 43450 (Dilation of esophagus, by unguided sound or bougie, single or multiple passes), confirms Catherine du Toit, CPC, PCS, a coder in Doylestown, Pa.

Potential problem: "Bougie" is a generic term for flexible esophageal dilators that are available in varying sizes. You might not see the term right in the operative notes, so you'll have to know what to look for.Two of the more common types of bougie dilators go under the names "Maloney" and "Savary," confirms Michele R. Hayes, CPC, CEMC, CGIC, who works for a large gastroenterology group in South Carolina.

Other types of dilators go by the names "Hurst" and "American." "My physicians tell me that the Maloney is easier and less involved [to insert]," she explains. When things get more difficult during the dilation, the gastroenterologist might opt for the sturdier Savary dilator.

Unguided dilation with a Maloney bougie (or Hurst type) is reported to have a higher rate of perforation complication compared to wire-guided dilation with Savary (or American) bougies.

The physician will often use the Savary when the stricture is very tight, or there is dyskinesia of the esophagus or another issue that would make a stiffer dilator passed over a guide wire preferable to the Maloney.

Best bet: If you see "Savary," "bougie," "Maloney," "Hurst," "American," or "dyskinesia" in the encounter notes, be on the lookout for a bougie dilation.

Providers generally use Savary bougies for dilation with a guide wire placed during the endoscopic procedure prior to removing the endoscope. When this occurs, do not report 43450 separately for the dilation.

Example: The gastroenterologist performs a diagnostic EGD on a patient who is having difficulty swallowing. During the EGD the physician notices an esophageal stricture that barely accommodates the instrument. He examines the entire stomach and duodenum and places a guide wire before removing the instrument.

Dilation was performed using 14 mm and 15 mm Savary bougies over the guide wire.

On the claim, report 43248 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with insertion of guide wire followed by dilation of esophagus over guide wire) for the procedure.

The gastroenterologist might perform an upper gastrointestinal endoscopy (EGD) prior to a dilation. When this occurs, you can code for both, says Melissa Briggs, CPC, who works in coding and compliance at Cotton O'Neil Clinic in Topeka, Kan. For example, the gastroenterologist performs a level two E/M and a diagnostic EGD on a new patient who is having difficulty swallowing. During the EGD the physician notices an esophageal stricture, so after the scope is removed she performs a dilation with a Maloney bougie.

On the claim, report the following:

• 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, without or without collection of specimen[s] by brushing or washing [separate procedure]) for the EGD

• 43450 for the dilation

• 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making ...) for the E/M

• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99202 to show that the procedures were separate from the E/M.

• 530.3 (Stricture and stenosis of esophagus) appended to 43235, 43450, and 99202 to represent the stricture.

It depends on the insurer. At Briggs' office, she says that none of the payers they contract with require a modifier. Others, however, have a more mixed reaction to the modifier question.

"I would use modifier 51 (Multiple procedures), unless you know the payer does not require it," Hayes recommends.

"Fact is, one should always check with your carrier to see whether they want a 51 modifier for 43450 -- but usually we don't use any modifiers at all," says du Toit.

Best bet: Head off any confusion by checking with the payer before coding EGDs and bougie dilations for the same patient during the same encounter. You don't want to have to resubmit any claims, if you can avoid it.

For bougie dilation, you can report guidance separately if the gastroenterologist needs it to perform the procedure, says Briggs.

Example: The gastroenterologist performs a level-two E/M service on a patient who is experiencing dysphasia and trouble swallowing from a previously known distal esophageal stricture. The gastroenterologist begins an inoffice bougie dilation, but he is unable to insert the dilator satisfactorily. Using fluoroscopic guidance, the physician is able to place the dilator and finish the procedure. Final diagnosis is esophageal stenosis.

On the claim, report the following:

• 43450 for the dilation

• 74360 (Intraluminal dilation of strictures and/or obstructions [e.g., esophagus], radiological supervision and interpretation) for the guidance

• 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making ...) for the E/M

• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99212 to show that the E/M and other services were separate.

• 530.3 appended to 43450, 74360, and 99212 to represent the patient's condition.

Modifier issue(s): Again, you might need modifier 51 appended to 74360 -- or you might not, depending on payer preference. If you're unsure, check your carrier contracts or contact a rep before filing.

Also, if the physician performs the same procedure in the hospital, you'll need to append modifier 26 (Professional component) to 74360 to show that you are only billing for the gastroenterologist's services, not the fluoroscopy equipment.