Eleen Posted Tue 31st of July, 2012 18:36:41 PM
Procedure: Upper GI endoscopy 43239
the endoscope was passed under direct
vision. Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously. The Endoscope was introduced through the mouth, and advanced to the second part of duodenum
Indications: Personal history of malignant esophageal neoplasm
Patchy mild inflammation characterized by erythema was found in the gastric antrum.
The cardia and gastric fundus were normal on retroflexion though there was some nodularity noted at the GE junction.
The GE junction appeared at 41 cm and appeared largely unremarkable. No discrete mass noted. No obvious nodularity
appreciated though given history, biopsies taken near the GE junction. Evidence of scarring noted in the distal esophagus
from prior cryoablative therapy.
There was likely a small stricture noted in the distal esophagus just proximal to the GE junction with mild resistance felt
with passage of the endoscope and minimal heme noted with passage of the scope. It appears that this short segmental
stricture was dilated with passage of the endoscope. The overlying mucosa appeared smooth without any discrete
A TTS dilator was passed through the scope. Dilation with a 12-13.5-15 mm x 180 cm CRE balloon dilator was performed
at the gastroesophageal junction.
Normal examined duodenum.
- Mild antral gastritis.
- Mild nodularity noted at the GE junction as seen on retroflexion though appeared largely unremarkable
endoscopically as compared to prior examinations. Evidence of prior scarring noted from prior therapy to the distal esophagus.
Recommendation: - Await pathology results
Help. Thank you!
SuperCoder Answered Wed 01st of August, 2012 16:14:44 PM
"though given history, biopsies taken near the GE junction" leads to 43239
" Dilation with a 12-13.5-15 mm x 180 cm CRE balloon dilator was performed" leads to 43458
Since the diameter of balloon is more than 30mm, look under the 43220
It mentions-(For endoscopic dilation with balloon 30 mm diameter or larger, use 43458)