An esophagogastroduodenoscopy was performed with balloon dilation to open an esophageal stricture. After three attempts, the balloon dilation was unsuccessful. Jumbo biopsy forceps were then used to remove a section of the scarred stricture to create a wedge and prevent the stricture from constricting the esophageal lumen. What CPT code(s) would be reported for this procedure?
Based on the operative report submitted, although the procedure was not successful, it was performed.
Therefore, report CPT code 43249, Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with balloon dilation of esophagus (less than 30 mm diameter), for the balloon dilation procedure.
Since there is no code that adequately describes the removal of a section of the scarred esophageal stricture, report CPT code 43499, Unlisted procedure, esophagus. Please refer to Coding Clinic for HCPCS, Third Quarter 2007, Page 10, for additional information on “Discontinued procedures vs. unsuccessful procedures.”