If your clinician performs dilation during endoscopy to overcome strictures or obstructions in the upper GI tract, you have many codes to report the procedure. This includes some new ones and some old ones with changes to their descriptors that were introduced in 2014. Hone in on the right code with this expert advice.
Choose From Esophagoscopy or EGD Codes Depending on Extent of Scope
If your gastroenterologist performed balloon dilation to overcome a stricture, you will need to look at various factors to land the right code to report the procedure. Some of the aspects that you will need to look at include:
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The extent to which your gastroenterologist visualized using the endoscope,
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The diameter to which the balloon was inflated, and
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The condition that required dilation.
If your clinician performed balloon dilation and visualized only the esophagus, then you need to report the procedure using 43220 (Esophagoscopy, flexible, transoral; with transendoscopic balloon dilation [less than 30 mm diameter]). If your gastroenterologist visualized beyond the pyloric channel into the stomach, duodenum, and/or the jejunum, then you need to report the procedure using 43249 (Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus [less than 30 mm diameter]).
Heads up: The above mentioned codes can only be used when balloon dilation is done up to a diameter of 30 mm. If your gastroenterologist dilates the balloon equal or greater than 30 mm as is done in the case of a person suffering from achalasia (to break open the muscle fibers of the lower esophageal sphincter), you need to report this procedure with one of the following two codes again depending on the extent to which your clinician extended the scope:
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43214 (Esophagoscopy…with dilation of esophagus with balloon [30 mm diameter or larger] [includes fluoroscopic guidance, when performed])
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43233 (Esophagogastroduodenoscopy…with dilation of esophagus with balloon [30 mm diameter or larger] [includes fluoroscopic guidance, when performed]).
Example: Your gastroenterologist decides to perform a dilation procedure for a patient suffering from dysphagia due to GERD not responding to previously prescribed proton pump inhibitors and oral budesonide. Your gastroenterologist performs an esophagoscopy along with TTS balloon dilation (Through The Scope) to relieve the dysphagia symptoms that the patient is experiencing.
Your clinician dilated the balloon within 30 mm diameter and extended the scope into the stomach to check this area for any abnormalities. He noted that there were no abnormalities in the stomach of any significance.
What to report: Since your clinician extended the scope into the stomach, you will have to report an EGD code and not the esophagoscopy balloon dilation code. So, you report the procedure using 43249.
Capture These Codes for Guide Wire Dilations
Owing to the difficulty of passing the dilators and their correct placement for overcoming strictures, your gastroenterologist might use guide wires prior to the use of a dilator. These guide wires might be placed using an endoscope. In such a scenario, you will not use the above mentioned dilation codes but instead choose other CPT® codes to report the procedure.
“With any esophageal dilation procedure there is the significant risk of perforation of the esophageal walls, so your gastroenterologist will often use endoscopy during the procedure to help decrease complications,” says Michael Weinstein, MD, Gastroenterologist at Capital Digestive Care in Washington, D.C., and former representative of the AMA’s CPT® Advisory Panel. “Some types of dilation can be done with the scope in place and in others the scope is removed after a guidewire is inserted and before dilation is performed.”
You will again have to determine the extent to which the scope was advanced to arrive at the right code for the procedure. So, you report 43226 (Esophagoscopy…with insertion of guide wire followed by passage of dilator[s] over guide wire) if only the esophagus was visualized and choose 43248 (Esophagogastroduodenoscopy…with insertion of guide wire followed by passage of dilator[s] through esophagus over guide wire) if your gastroenterologist advanced the scope beyond the pyloric channel.
Coding tip: If you see the word “American” or “Savary” to describe the dilator that is used, then you can be assured that your gastroenterologist used a guide wire prior to the dilation procedure.
Don’t Report Dilation With These Procedures
When your clinician performs a dilation to overcome an obstruction or a stricture and then proceeds to perform other endoscopic procedures, be sure to check Correct Coding Initiative (CCI) edits to check whether the procedures are bundled. Also, CPT® do not allow you to report dilation procedures when your clinician performs placement of an esophageal stent or performs an ablation.
So, you cannot report dilation codes such as 43214 or 43220 when your clinician performs these procedures in the same session:
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43212 (Esophagoscopy, flexible, transoral; with placement of endoscopic stent [includes pre- and post-dilation and guide wire passage, when performed])
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43229 (…with ablation of tumor[s], polyp[s], or other lesion[s] [includes pre- and post-dilation and guide wire passage, when performed])
Settle For These Codes to Report Unguided Dilations
When your gastroenterologist uses a dilator without using the aid of endoscopy or a guide wire or performs a diagnostic endoscopy that is removed prior to the use of a dilator, you need to report the procedure using 43450 (Dilation of esophagus, by unguided sound or bougie, single or multiple passes).
If your gastroenterologist performed an endoscopy prior to the procedure, then you need to report it separately using 43235 (Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed [separate procedure] ) or 43200 (Esophagoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed [separate procedure]) ) depending on the extent of the visualization. “If a biopsy or other endoscopic therapeutic technique was performed then you will choose the appropriate code from the Esophagoscopy or Upper Gastrointestinal Endoscopy family of codes,” Weinstein adds.
Coding Tip: If you see the use of a “Maloney” dilator, then you can be certain that your gastroenterologist performed an unguided dilation (43450) and choose one of the above mentioned codes to report the endoscopy portion of the procedure.
In the rare case that your gastroenterologist performs dilation over a guide wire that was not placed using an endoscope, you will need to report the procedure with 43453 (Dilation of esophagus, over guide wire).
Don’t Forget to Report Fluoroscopy Separately
In many instances, your gastroenterologist will choose to take the help of fluoroscopy for the placement of the dilators in the correct position prior to their use. In such a scenario, don’t forget to report the supervision and interpretation of the fluoroscopy separately in addition to the dilation procedure that you are reporting. You will need to use 74360 (Intraluminal dilation of strictures and/or obstructions (e.g., esophagus), radiological supervision and interpretation) to report the procedure.
Caveat: If you look at CPT® guidelines for 74360, you will see that you cannot use this code in conjunction with balloon dilation codes, 43214 and 43233. So, if your clinician uses fluoroscopy for balloon dilation beyond 30 mm, then you should only report the dilation code and not report the fluoroscopy code separately.
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