It will be 43220.

Because there are many different ways that a gastroenterologist can dilate an esophagus, theres an often confusing array of dilation codes from which to chose. The type of dilator used and whether an endoscope and/or a fluoroscope were employed during the procedure will determine which CPT codes should be reported. In addition, not all manipulation codes used to report a dilation include an endoscopy in their description, and that procedure may have to be reported separately if it is performed by the gastroenterologist.

Esophageal dilations are performed when there is a stricture or abnormal narrowing of the esophagus, states Jane Allaire, RN, CGRN, a nurse endoscopist at the National Naval Medical Center in Bethesda, Md. The stricture could be due to a variety of causes, including a tumor, prolonged use of a nasogastric tube or complications from gastrointestinal reflux disease.

Five Categories for Classifying Dilations

Although dilation procedures will vary due to the nature, size and location of the stricture, the most frequent methods for reporting esophageal dilations can be summarized in the following five categories:

1. Dilation by balloon of less than 30 mm diameter: The gastroenterologist performs an endoscopy to visualize the esophagus, and then a deflated balloon is placed through the scope and across the stricture, explains Allaire. The endoscope remains in place while the balloon is inflated to a diameter of less than 30 mm.

Code 43220 (esophagoscopy; with balloon dilation less than 30 mm diameter) or 43249 (upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with balloon dilation of the esophagus less than 30 mm diameter) should be used to report this particular procedure, says Pat Stout, CMC, CPC, an independent gastroenterology coding consultant in Knoxville, Tenn.

Code 43249 includes an EGD (esophagogastroduodenoscopy) in its description, which means that it should be used when the endoscope passes the pyloric channel and extends down into either the duodenum and/or jejunum. Code 43220 includes an esophagoscopy in its description and is used when the endoscope passes the diaphragm but not the pyloric channel. The gastroenterologist may pass the endoscope all the way into the stomach, notes Stout, and then dilate the upper esophagus before removing the scope. In that case, code 43249 should be reported.

The standard practice is to code for the endoscopic family in which the gastroenterologist was able to advance the scope, she explains. If the scope was extended into the stomach and into either the duodenum or jejunum for reasons of medical necessity, then it is appropriate to report the work done as an EGD.

It also is not uncommon for a gastroenterologist to perform an EGD the first time a patient is dilated, but perform an esophagoscopy during dilations that may occur a few months later. The gastroenterologist in that situation would report 43249 for the initial session and 43220 for the subsequent dilations.

2. Dilation over endoscopically placed guide wire: The gastroenterologist will perform an endoscopy to visualize the stricture and to pass a guide wire into the stomach. The endoscope is then removed from the patient, but the guide wire remains in place. A dilator (or series of dilators) with a lumen in the middle is threaded onto the guide wire and advanced until the dilator reaches the stricture. The dilators used in this procedure also may be referred to as American or Savary-type dilators, reports an article in the spring 1994 CPT Assistant.

Code 43248 (upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with insertion of guide wire followed by dilation of esophagus over guide wire) is used to report both the insertion of the guide wire and the subsequent passage of the dilator when done during an EGD. Code 43226 (esophagoscopy; with insertion of guide wire followed by dilation over guide wire) is used when the guided dilation is done during an esophagoscopy.

As with balloon dilations, if a gastroenterologist extends the endoscope into the stomach and returns to perform a dilation in the esophagus, 43248 can be reported. Or as with the balloon dilation, the gastroenterologist may perform an EGD the first time a patient is dilated, but perform only an esophagoscopy during dilations that may occur a few months later. In that case, the gastroenterologist would report 43248 for the initial session and 43226 for the subsequent dilations.

3. Unguided dilator, endoscope and/or fluoroscope optional: Some dilators can be inserted into the patient without the use of an endoscope or guide wire, explains Allaire. An endoscope may be used to visualize the stricture, but the scope will be removed from the patient before the dilation is done. The gastroenterologist frequently may use a fluoroscope here to guide the placement of the dilator. According to the spring 1994 CPT Assistant , Hurst and Maloney-type dilators are used during this procedure.

Code 43450 (dilation of esophagus, by unguided sound or bougie, single or multiple passes) is used to report the non-endoscopic insertion and manipulation of the dilator, says Stout. If an endoscopy is performed before the dilation, that should be reported separately.

If an EGD with biopsy (43239) is performed before the insertion of a Maloney dilator, a gastroenterologist submitting a claim to Medicare or a private payer that follows Medicare rules should report 43239 first because it has the higher relative value unit (RVU) and expect reimbursement to be 100 percent of the standard fee. Code 43450 with modifier -51 (multiple procedures) attached should be reported next. Reimbursement will be 50 percent of the standard fee because Medicares multiple procedure rules apply.

The gastroenterologist also can report the use of the fluoroscope separately if he or she does the supervision and interpretation. If a gastroenterologist uses a fluoroscope in the previously mentioned example, 74360 (intraluminal dilation of strictures and/or obstructions [e.g., esophagus] radiological supervision and interpretation) with modifier -51 attached also should be reported. Reimbursement for the fluoroscope will be 50 percent of the standard fee because the Medicare multiple procedures rules apply.

Allaire adds that unguided dilations can be performed without the aid of either an endoscope or fluoroscope, especially when done during a subsequent dilation session. Then, only manipulation code 43450 should be reported.

4. Dilation over a guide wire, no endoscope: Although not frequently used, code 43453 (dilation of esophagus, over guide wire) is for cases in which a dilator is inserted over a guide wire that was not placed endoscopically, Stout says.

In this situation, the gastroenterologist may use a fluoroscope to visualize the placement of the guide wire. Code 74360 should be used to report the supervision of the fluoroscopy, and reimbursement should be 100 percent of the standard fee because this is the higher-valued procedure. The dilation code 43453 should have modifier
-51 attached, and reimbursement should be 50 percent of the standard fee because the multiple procedures rules apply.

5. Dilation by balloon greater than 30 mm diameter for treatment of achalasia: When esophageal dilation is being performed to treat achalasia, the muscle fibers of the lower esophageal sphincter are broken and not just stretched with a balloon dilator that is greater than 30 mm in diameter.

Because there is a risk that the esophagus could be perforated during the dilation, it is likely that an endoscope and fluoroscope both will be used during this procedure, explains Allaire. A gastroenterologist might perform, for example, a diagnostic EGD (43235) to visualize the esophagus and insert the balloon, and use a fluoroscope to visualize the inflation of the balloon.

In this situation, 43458 (dilation of esophagus with balloon [30 mm diameter or larger] for achalasia) should be used first to report the inflation and manipulation of the balloon dilator because it is the procedure with the higher RVU. Reimbursement for the manipulation with balloon should be 100 percent of the standard fee. Code 43235 with modifier -51 attached should be used to report the EGD; reimbursement should be 50 percent of the standard fee because the multiple procedures rules apply. Code 74360 with modifier -51 attached should be used to report the fluoroscopy; reimbursement should be 50 percent of the standard fee because the multiple procedures rules apply.

Dilations Reported With Removal of Foreign Body

Balloon dilation also can be used to remove foreign bodies lodged in the esophagus. But a note in the CPT manual at the end of the esophagus-manipulation subsection states that 43215 (esophagoscopy, rigid or flexible; with removal of foreign body), 43247 (upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of foreign body) or 74235 (removal of foreign body[s], esophageal, with use of balloon catheter, radiological supervision and interpretation) should be used to report these procedures.

Finally, the endoscope itself sometimes may be used to dilate a stricture, with no other type of dilator used during that session. Because there is no code for dilation via an endoscope, reports the January 1997 CPT Assistant, only the endoscopy can be reported.

Not all Medicare carriers or private insurance companies require the use of modifier -51 when reporting multiple procedures. Some payers require the use of a different modifier, and others require no modifier at all. Gastroenterologists should check with their local payers for specific coding instructions. For more on Medicares multiple procedures rules, please see Multiple Procedures: Increase Reimbursement With Correct Modifiers and ICD-9 Codes in the March 2000 Gastroenterology Coding Alert and Optimize Billing for Three or More Endoscopic Procedures Performed on the Same Day in the May 2000 issue.

Need cpt for remicade infusion thru port-a-cath. Our nurse is infusing
remicade thru a port-a-cath that has been implanted just for remicade infusion. Nurse states the cpt 96413 is not the correct code for this and 96446 should be the appropriate code .Does anyone do this type of infusion and what code is used?

incorrect cpt given for the above sincerio 96446 is for peritoneal cavity....so with that said, what would be the cpt for remicade infusion through a previously placed port-a cath .Port-a-cath accessed with huber needle,cath as flushed with Heparin.

I need help with an ICD-9 code for Narcotic Bowel Syndrome

"Narcotic bowel syndrome (NBS) is a subset of opioid bowel dysfunction that is characterized by chronic or frequently recurring abdominal pain that worsens with continued or escalating dosages of narcotics. This syndrome is under recognized and may be becoming more prevalent. This may be due in the United States to increases in using narcotics for chronic non-malignant painful disorders, and the development of maladaptive therapeutic interactions around its use. Treatment involves early recognition of the syndrome, an effective physician patient relationship, graded withdrawal of the narcotic according to a specified withdrawal program and the institution of medications to reduce withdrawal effects."

"It has long been recognized that opiates affect gastrointestinal motility. These effects, known as opioid bowel (or gastrointestinal) dysfunction are manifest as constipation, nausea, bloating, ileus and sometimes pain (1–3). When pain is the predominant symptom, the condition has been termed narcotic bowel syndrome (NBS)."

I would recommend the 789.0x series depending on the location of the pain (probably generalized) and the E code for adverse effect and the poisoning code for illicit drug use. It should not be classified as postoperative pain as it is due to an effect of the drugs whether the patient had surgery or not.

96413 is a likely code. Payers are free to determine which non-chemotherapy agents they pair with chemotherapy administration codes, which reflect a higher level of skill and therefore a higher fee than non-chemo admin codes. You're likely to find that payers instruct you to report Remicade infusions using chemotherapy infusion codes, such as 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) and +96415 (Chemotherapy administration, intravenous infusion technique; each additional hour [List separately in addition to code for primary procedure]). Recall that CPT includes access to indwelling IV, subcutaneous catheter or port, and flush at conclusion of infusion in the admin code.

How do I bill an EGD with capsule endoscopy placement

Prior to placement of a Bravo capsule, your gastroenterologist will generally need to perform an EGD. The purpose of the EGD is multiple as it helps your gastroenterologist assess the location of anatomical landmarks such as the lower esophageal sphincter or the squamocolumnar junction to help place the Bravo capsule. The procedure also helps in the assessment of the signs and symptoms that the patient is experiencing.

If the evaluation through EGD prompted the placement of the Bravo capsule, then the EGD procedure is billed on the date that it was placed. You will report it 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]).

If your gastroenterologist performs a biopsy during the endoscopy, you will need to report it with 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple) with the billing date on the day it was performed. If the only reason to perform the EGD is to determine the location for a Bravo placement, then the endoscopic procedure is considered part of the Bravo CPT code and is not separately billable.

In general, a physician needs to perform an EGD to evaluate the symptoms which are also prompting the use of a Bravo capsule. In order to place a Bravo capsule the physician needs to know the location of the lower esophageal sphincter or squamocolumnar junction. This is where it gets tricky.

When an endoscopy is performed to investigate symptoms then the endoscopy procedure will be billed on the date it was performed with the ICD-9 code representing the patient's symptoms. The CPT code might be 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]) or 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple), depending on the service. At the same session the physician might also decide to place a Bravo capsule using the measurements obtained during the endoscopy (billable with 91035, Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode placement, recording, analysis and interpretation). The date of service for the claim for the Bravo capsule will be when the recorder is retrieved 2-4 days later and the physician is sure that data was captured for analysis.

However, if the gastroenterologist performed an endoscopy recently (roughly within several months) to evaluate the symptoms at some date prior to Bravo placement, then it should not be necessary to repeat it just to get the location needed for the Bravo capsule placement. The second endoscopy would not be medically necessary and therefore not separately billable. You should include this in the Bravo claim.

Patient had EDG with biopsy removal (43239) with a BRAVO placement in the same operative session. I have read it is correct to bill 43239 on the date the the procedure took place and wait to bill 93010 until the results are complete for the BRAVO to include the interpretation and report.

Is it ever acceptable to bill 43239 and 43241 on the date of the procedure and then bill 93010-26 when the physician interprets and reports the BRAVO?

Physician perfromed Exam under Anesthesia , anastomotic dilation using a Hegar dilator, flexible sigmoidoscopy. I wanted to use 45340 but it uses a ballon dilation. Can any one help?

Prior to placement of a Bravo capsule, your gastroenterologist will generally need to perform an EGD. The purpose of the EGD is multiple as it helps your gastroenterologist assess the location of anatomical landmarks such as the lower esophageal sphincter or the squamocolumnar junction to help place the Bravo capsule. The procedure also helps in the assessment of the signs and symptoms that the patient is experiencing.

If the evaluation through EGD prompted the placement of the Bravo capsule, then the EGD procedure is billed on the date that it was placed. You will report it 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]).

If your gastroenterologist performs a biopsy during the endoscopy, you will need to report it with 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple) with the billing date on the day it was performed. If the only reason to perform the EGD is to determine the location for a Bravo placement, then the endoscopic procedure is considered part of the Bravo CPT code and is not separately billable.

The Bravo capsule is read when it is retrieved after a period of about two to four days after it has been placed. You will need to report the Bravo capsule with 91035 (Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode placement, recording, analysis and interpretation) with the billing date on the day when it is read.

A modifier 26 (Professional component) is placed if your gastroenterologist is performing the reading (professional component) only. If you are claiming for both the technical and the professional component of the Bravo capsule placement, you will only bill with 91035.

patient dx'd with above - would 536.2 be appropriate?

It does look like you're going to have to use 45999 (Unlisted procedure, rectum). The coding depends on the depth of the intended examination and the specific tool used. Don't be tempted to use a CPT code that sounds similar to the service your physician performed.

Why not? For the anal canal, rectum, and the sigmoid colon (6 cm-25 cm), you'd normally choose a proctosigmoidoscopy code: 45303 (Proctosigmoidoscopy, rigid; with dilation [e.g., balloon, guide wire, bougie]). This covers the dilation, but specifically says the physician's using a rigid proctosigmoidoscope.

If the doctor examines the entire rectum, sigmoid colon, and perhaps as far as the splenic flexure (26 cm-60 cm), you'd normally use a sigmoidoscopy code: 45340 (Sigmoidoscopy, flexible; with dilation by balloon, 1 or more strictures). Your physician's using a flexible scope, but a Savory dilator isn't a balloon.

Bolster your claim: In your notes, refer to whichever of those two codes is most appropriate based on the depth of the examination as examples for purposes of reimbursement. You don't want to leave it up to the payer to figure out what a procedure is comparable to.

Absolutely! Cyclical vomiting is represented by 536.2 only.

When a patient is due for a Colonoscopy for history of colon polyps V12.72, but the patient has documented lifelong Chronic diarrhea/constipation can we still code G0105? We are not doing the colonoscopy for these symptoms.

Patient came into the hospital on 12/20 @ 14:32 and was discharged on 12/22 17:00. During her stay she remained in observation status and was never admitted to inpatient. My dr saw the pt on 12/20 and billed an observation code but he also followed up with pt on 12/21 and used 99232 which ins denied since pt was never admitted to inpatient. What code should he use for the follow up visit on 12/21? Would an office visit e/m code work?

Physican is performing a Laparoscopic cholecystectomy, but the patient is also twelve weeks pregnant. Should 646.83 be the primary DX and 574.20 secondary?

Because there is stone in the gallbladder, you should report 646.83 (Other specified complications of pregnancy; antepartum condition or complication) with 574.20 as a secondary code.

We are working on this. Please be patient.

Hi, Code 99232 is for hospital inpatient service whereas the patient was in observation; this is the reason it was denied by the insurance. When the patient came in observation on 12/20, it was his/her initial visit to observation. The next day i.e. 12/21 is subsequent care in observation and should have been billed with subsequent observation care codes (99224, 99225, or 99226).