Gastroenterology Coding Alert

Question: I code for an ASC and one of our gastroenterologists does an endoscopy first, removes the scope, then passes a #56 mercury bougie through the mouth, esophagus and into the stomach. I have been coding the endoscopy and dilation separately because he states he removes the scope before passing the bougie. I have been using procedure code “43450” with modifier 51 in addition to the endoscopy code. Does this sound correct?

Michigan Subscriber

Answer: In the case scenario that you have described, your gastroenterologist is performing two different procedures in the same session. As you have described, your gastroenterologist is first performing an upper endoscopy to visualize the gastrointestinal tract. You report this procedure with 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).

After this, he is removing the scope and then performing an unguided dilatation with a mercury- weighted bougie (Maloney bougie) without using any endoscopic aid or guidewire. You report this dilatation procedure using 43450 (Dilation of esophagus, by unguided sound or bougie, single or multiple passes). You will use only one unit of 43450 even if your gastroenterologist passes in sequentially increasing sizes of the dilators to overcome the stricture.

You are correct until this point. However, you have pointed out that you use the modifier 51 (Multiple procedures) to 43450. But you do not have to use this modifier or any other modifier such as modifier 59 (Distinct procedural service) with these two codes as they are not bundled under Correct Coding Initiative (CCI) edits. So you will only have to report the two codes, namely, 43235 and 43450 with no modifiers appended to any of the two codes. The diagnosis codes for the endoscopic procedure will likely be related but not always identical. 

Often an esophageal stricture will require a series of dilations with increasingly larger bougies to gradually stretch the diameter of the esophagus to a width were the patient’s symptoms are alleviated.  Once a diagnosis is identified on the initial endoscopy the physician should be able to perform the series of esophageal dilations with Maloney bougies without additional endoscopy.