Gastroenterology Coding Alert

Test your coding knowledge.  Determine how you would code this situation before looking at the box below for the answer.   Question: What is the correct way to code an esophagogastroscopy and esophageal dilation that did not advance into either the duodenum or jejunum?
Louisiana Subscriber     Answer: The operative report that you sent with your question indicates that the gastroenterologist performed an esophagogastroscopy and an esophageal dilation using Savory dilators. The esophagogastroscopy is a variation of an upper gastrointestinal endoscopy and is a component of the esophageal dilation. Therefore, you should bill only for the dilation.
 There are two codes you could use: 43226 (esophagoscopy, rigid or flexible; with insertion of guide wire followed by dilation over guide wire) when the endoscope was not advanced beyond the esophagus, or 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) when the endoscope was advanced beyond the esophagus and into the stomach and either the duodenum or the jejunum.
 While your question indicates that the endoscope did not advance beyond the esophagus, the operative report indicates otherwise. It states that "the endoscope was advanced into the stomach & the instrument was positioned in the distal body of the stomach." The word "distal" signals that the endoscope was advanced to the far end of the stomach and did approach either the duodenum or jejunum. Check with your gastroenterologist to make sure this is what happened, but you should probably bill 43248 for this procedure.