Do This When Coding Dysphagia and Stricture Found During Endoscopy
Question: A patient with a history of gastroesophageal reflux disease (GERD) presented with new-onset dysphagia. Our gastroenterologist performed an upper gastrointestinal (GI) endoscopy and identified a benign esophageal stricture. They then performed a dilation of the stricture during the same procedure. What diagnosis and procedure codes should I include on the claim? Michigan Subscriber Answer: When coding this encounter, begin by identifying the primary reason for the visit. Although the patient has a history of GERD, the encounter was prompted by new-onset dysphagia, and the procedure performed was related to the esophageal stricture found during the endoscopy. Let’s start with the primary diagnosis. Report R13.10 (Dysphagia, unspecified), as this was the main reason for the visit. For a secondary diagnosis, you can also report K21.9 (Gastro-esophageal reflux disease without esophagitis) to reflect the patient’s documented history of GERD. Finally, you can report K22.2 (Esophageal obstruction) to capture the benign esophageal stricture found during the procedure. Now let’s look at the procedure itself. If the stricture was dilated using a balloon during esophagoscopy, report 43220 (Esophagoscopy, flexible, transoral; with transendoscopic balloon dilation (less than 30 mm diameter)). If the dilation was done during an esophagogastroduodenoscopy (EGD), report 43249 (Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter)). Suzanne Burmeister, BA, MPhil, Medical Writer and Editor
