Results 1 to 4 of 4

multiple dilation help!

  1. #1
    Exclamation multiple dilation help!
    Medical Coding Books
    I am new to gastro coding so I just want to make sure I am doing it right.

    CLINICAL INDICATION: Cervical dysphagia, distal dysphagia, probable cervical web, possible distal stricture.

    Upon obtaining informed consent, the patient was given MAC anesthetic - see anesthesia report. The Fujinon endoscope was introduced into the small intestine. The patient had a gastrectomy and Bill Roth I anastomosis. The gastroenterostomy, remaining stomach, and enterostomy were all normal. Retroflexion revealed a hiatal hernia. There was a distal stricture. This was dilated with a 60 Fr balloon dilator 30 seconds x two. The esophagus was normal. There was no evidence of esophagitis. In the upper esophagus one could see a constriction consistent with a cervical web. This was dilated to a 54 Fr balloon dilator when one could see disruption of the stricture with some minimal bleeding, which is normal after post-stricture dilatation. The instrument was then withdrawn. The patient tolerated the procedure well.

    Dysphagia primarily due to an upper cervical web - dilated to 54 French.
    Hiatal hernia and distal stricture - dilated to 60 French.

    We will review medications to make sure that she does not have any medication that is exacerbating her reflux and causing strictures.
    Follow up with me in the office.

    43235 787.29 553.3
    43450 787.29 530.3
    43450 59 553.3 530.3

    some instruction would be appreciated
    Last edited by ASC CODER; 11-24-2009 at 01:14 PM.

  2. #2
    Could someone give me direction please

  3. #3
    Patients with altered anatomy, as this record indicates can be a bit challenging. The distal stricture appears to be at the altered gastric outlet. Look at CPT 43245 for this intervention. For the esophageal stricture, it appears as if a through-the-scope balloon dilator was used. Look at CPT 43249. Your choice of code 43450 is for dilation only without the use of an endoscope. I would ask the physician if the verbiage of these two codes describes what was provided.
    Jenny Berkshire, CPC, CEMC, CGIC

  4. #4
    Thank you!!!

Similar Threads

  1. Modifiers with multiple specimens with multiple IHC stains
    By ColqPath in forum Pathology & Clinical Laboratory
    Replies: 10
    Last Post: 05-09-2014, 02:43 PM
  2. Coding Multiple Procedures on Multiple Digits
    By in forum Medical Coding General Discussion
    Replies: 2
    Last Post: 01-02-2014, 07:43 PM
  3. Coding Multiple Procedures on Multiple Digits
    By in forum Medical Coding General Discussion
    Replies: 0
    Last Post: 01-01-2014, 11:34 AM
  4. EGD with Savory guide dilation and Maloney dilation
    By in forum Gastroenterology
    Replies: 3
    Last Post: 12-29-2010, 08:48 AM
  5. Replies: 1
    Last Post: 10-10-2008, 09:50 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.