Evaluate This EGD and Stricture Dilation Coding Conundrum
Question: A 68-year-old patient with longstanding gastroesophageal reflux disease (GERD) and esophagitis presented with worsening dysphagia to solids. The gastroenterologist performed an esophagogastroduodenoscopy (EGD) to the duodenum. In the esophagus, the physician found a tight distal esophageal stricture measuring approximately 9 mm, which they dilated to 15 mm with a through-the-scope balloon under direct visualization. Peptic stricture is listed under the findings. What should I report for this encounter? Alabama Subscriber Answer: Use 43249 (Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter)) to report the EGD with the balloon dilation of the esophagus under direct visualization. This code is reserved for dilations of less than 30 mm, which applies to your case since the gastroenterologist dilated the area to 15 mm. For the diagnosis codes, you’ll assign K22.2 (Esophageal obstruction) to report the peptic stricture; K22.2 lists stricture of esophagus as another condition that you can report with the code. Also, use K21.00 (Gastro-esophageal reflux disease with esophagitis, without bleeding) to report the patient’s longstanding GERD with esophagitis. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
