Gastroenterology Coding Alert

Question: What CPT^® code would you use for the following case scenario:

“Scope passed up to middle esophagus, no stricture seen. Wire confirmed in the stomach and CRE balloon used to dilate up to 9mm.” Since a guide wire was used, would you use 43226 or as a balloon was used, would you use 43220?

Tennessee Subscriber

Answer: When your gastroenterologist performs dilation, you will have to consider the following factors before you choose the appropriate code that you will have to report. You will choose the code depending on the type of dilator that your gastroenterologist used and also based on whether he used endoscopy and/ or fluoroscopy to perform the procedure. You will also have to consider the extent to which the scope was introduced in the gastrointestinal tract.

In your case scenario, your gastroenterologist used a balloon to dilate the esophagus. So, you will have to report the procedure using 43220 (Esophagoscopy, rigid or flexible; with balloon dilation [less than 30 mm diameter]). But, again, you will have to ensure that your gastroenterologist did not advance the scope to view areas of the stomach, duodenum and/or the jejunum. If the scope was extended to view these areas, you will have to use the CPT^® code 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]) to report the procedure.

As you have pointed out, since the guide wire was used, you’ll need to discern whether to use 43226 (Esophagoscopy, rigid or flexible; with insertion of guide wire followed by dilation over guide wire) or 43220. You’ll need to determine why the guide wire was used and if it was used to dilate the esophagus. Some balloon systems use a guide wire and some do not but the main point is that this was a balloon catheter. 

You can use 43226 only if your gastroenterologist used the guide wire with a bougie system that incorporates the guide wire to dilate the esophagus, not otherwise. (for example, Savory, M-Flex)

In your case scenario, your gastroenterologist used the guide wire to guide the placement of the balloon catheter for the dilation. So, you cannot use 43226 in this case scenario.