Transnasal KTP laser excision of esophageal stenosis with CRE balloon dilation and injection


True Blue
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Hello ALL

I'm coming up with CPT 43499 (unlisted esophagus) and benchmarking it to CPT 43229 + 43204.

Curious to know if any of you have coded this procedure. And what your using.

The patient was brought to the operating room and left on the gurney in the upright position. The nasal cavity had been packed in Preanesthetic Care Unit with nasal pledgets soaked in Afrin and 4% lidocaine. A nasal cannula was placed into the patient's oral cavity and then the pledgets were removed. A transnasal esophagoscope was advanced through the left nasal cavity and advanced to the level of the post cricoid region. With gentle insufflation, the stenosis was immediately noted and was significant. There did appear to be a thick scar band proximally, though with some manipulation the TNE scope was able to pass through this area into the distal esophagus, which appeared normal. However, it was decided that the laser would be used to help incise the scar tissue. Four different cuts were made with the KTP laser then, which was placed through the channel of the scope. This was on a setting of 30 watts, 15 millisecond pulse with 2 pulses per second. Cuts were made at the 12 o'clock, 10 o'clock and 9 o'clock positions, as well as at the 7 o'clock and 3 o'clock positions. Once this was done, the Jagwire was advanced through the channel of the scope all the way into the stomach and it was left in place while the scope was withdrawn, and an 18 to 20 mm CRE balloon was advanced over the Jagwire. It was carefully advanced till the balloon was right at the level of the stenosis. Under direct visualization with the endoscope, the balloon was inflated multiple times for a minute each up to 6 atmospheres. There appeared to be excellent dilation noted and Kenalog was then injected with an endoscopic needle through the channel into separate locations. Approximately 0.9 cc of Kenalog 40 mg/mL was injected. The stenotic area was once again dilated. There was no evidence of any significant mucosal trauma. There was the minor trauma noted with dilation. No evidence of perforation. The scope was withdrawn without incident as was the balloon. Patient was awakened and returned to recovery in stable condition with no immediate complications. I was present and intimately involved with the entire procedure.


Grantsville, UT
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I too couldn't find a code for these procedures via transnasal approach. I would use the unlisted code with 43229 or 43220 for comparison along with 43201. I wouldn't use 43204 as that is for injection of a sclerosing agent to treat enlarged blood vessels, which according to the documentation wasn't the case.
Hopefully this is helpful,