tci General Surgery Coding Alert - 2020 Issue Q1

Reader Question: Details Guide Esophageal Dilation Case

Question: How should we code the following esophageal dilation case that includes both a balloon dilation and a guidewire? “Scope passed to middle esophagus; wire advanced to stomach; CRE balloon dilation up to 8 mm.” SuperCoder Subscriber Answer: The best choice for this case is 43220 (Esophagoscopy, flexible, transoral; with transendoscopic balloon dilation (less than 30 mm diameter)). The key components for selecting an esophageal dilation code are the type of dilator and the extent of scope introduction into gastrointestinal tract. The documentation indicates that the surgeon did not advance the scope to the stomach, so that...

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