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Esophageal stricture dilation with scope

  1. Default Esophageal stricture dilation with scope
    Medical Coding Books
    Physician performed an upper endoscopy with pentax video endoscope that revealed an esophageal stricture. "The tubular view of the esophagus revealed an esophageal stricture which admitted the scope with slight pressure, and this did dilate the stricture. The instrument was advanced through the rest of the esophagus, which was appeared normal. Diagnostic Impression: Dysphagia secondary to a proximal esophageal stricture, dilated with the scope." (This is per the actual procedure report)

    My question is, which CPT code do I report for the physician? The ASC wants to report a standard endoscopy-43235. I feel i may be able to code 43245?? Any help would be greatly appreciated. Thank you!!

  2. Default
    Quote Originally Posted by taly View Post
    Physician performed an upper endoscopy with pentax video endoscope that revealed an esophageal stricture. "The tubular view of the esophagus revealed an esophageal stricture which admitted the scope with slight pressure, and this did dilate the stricture. The instrument was advanced through the rest of the esophagus, which was appeared normal. Diagnostic Impression: Dysphagia secondary to a proximal esophageal stricture, dilated with the scope." (This is per the actual procedure report)

    My question is, which CPT code do I report for the physician? The ASC wants to report a standard endoscopy-43235. I feel i may be able to code 43245?? Any help would be greatly appreciated. Thank you!!

    I bill for an asc, and i think the asc you speak of needs to do their homework because they are losing money by billing a diagnostic egd. first of all, if the doctor dilated the esophagus then it needs to be billed that way. You are correct in that you need to bill the scope with dilatation. Note -- when doctor does an unguided dilatation and biopsies both 43239 and 43450-59 can be billed with the unguided dilatation.

  3. #3
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    I code for an ASC as well and I'm not sure why they want to bill a 43235. I don't have my cpt book in front of me to see what the description is for 43245. I use 43248 a lot for egd w/ dil.

  4. #4
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    Note that 43245 is dilation of a gastric outlet; this appears to be an esophageal stricture and the only code defined for dilation of esophageal stricture in the EGD family is 43248, dilation using a guide wire and 43249 dilation using a balloon. There are the dilation codes 43450-43456, but all define a device (e.g. guide wire, balloon, etc.) used for dilation, not the scope. I would suggest 43235 is the appropriate code for this procedure.
    Jenny Berkshire, CPC, CEMC, CGIC

  5. #5
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    I have to say that I agree with Jenny. The gastric outlet code is inappropriate for this op report. I also bill for an ASC and several gastroenterologists. This might be a situation where a modifier 22 would be appropriate for the physician portion of the claim. Then you can send with records illustrating what the increased services were.

  6. Default
    Quote Originally Posted by j.berkshire View Post
    note that 43245 is dilation of a gastric outlet; this appears to be an esophageal stricture and the only code defined for dilation of esophageal stricture in the egd family is 43248, dilation using a guide wire and 43249 dilation using a balloon. There are the dilation codes 43450-43456, but all define a device (e.g. Guide wire, balloon, etc.) used for dilation, not the scope. I would suggest 43235 is the appropriate code for this procedure.
    you are right, 43245 is for gastric outlet and at the time i posted my response i did not have my book. With all due respect, the point is this....

    43235 is a diagnostic egd, where nothing but visualization is done. Once an actual surgical procedure, such as biopsy or dilatation is performed, you can no longer bill the diagnostic code and you need to bill the appropriate surgical code and in this case it would be the appropriate dilatation code for the esophagus, dependent on the methodology of the dilatation.
    This op notes states the dilatation was done thru the scope, this means it was guided. It was guided with a guide wire or a balloon that went thru the scope. The device is a key factor in determining whether or not you can bill additional procedures such as a biopsy at the same encounter. if this procedure were done as unguided, meaning scope was removed from patient and the esophagus was dilated without the use/visualization of the scope, then the scope was reinserted and advanced to the stomach where a biopsy was taken then you could bill both services.
    I too, have many years of working for a GI doc and have attended many courses on how to bill these procedures correctly.

    Lets not beat each other up over this, we are here to help but billing 43235 is an asc grouper 1 - whereas 43245 or 43248 is an asc grouper 2 with higher reimbursement.
    you cannot bill 43235 at all once a surgical procedure has taken place because the surgical procedure includes the diagnostic study.
    Last edited by capricew; 11-30-2010 at 11:26 PM. Reason: FORGOT IMPORTANT DETAIL

  7. #7
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    CWALDER,no one was trying to attack your position, we are just trying to help, as you are. :0)

    The point we were trying to share for an answer is this: The 43248 and 43249 are not indicated by the operative note that taly posted. You cannot just assume that a dilation was done with a guide wire, or with a balloon; the documentation has to support this. I believe that is where Jenny and I's point is coming from. I've never heard of dilation done just with the scope, I've heard of it done through the scope, but in this case it says that dilation was done with the scope. I get what your point is on the diagnostic issue, but documentation needs to state that a guide wire or balloon was used if such is the case. I'd have to say that I stand by my original post, along with Jenny's. No offense intended at all.

    Taly, I have to say that I'm sorry this is sparking so much back and forth on your question, I'm sure this isn't super helpful to you getting the answer you are looking for, but I think discussion is important so that we all can make sure that we are coding correctly, and are up-to-date on our knowledge of methodologies.

  8. Default
    No problem jen,
    the info given is vague, perhaps the best thing to do is query the physician on how the dilatation was performed whether it was by balloon or guidewire etc.....
    This way the proper information is obtained, it can be coded correctly, and it is also not downcoded for lack of information,
    sorry taly-- we all learn from these forums.

  9. #9
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    I would have to agree with the 43235. It seems the finding the stricture was an incidental finding so the scope, in general, wouldn't have been able to have been completed without pushing the scope into the stomach. If stricture was known about pre-procedure then the esophageal dilation code would be appropriate.

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