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Tanesha Posted Fri 02nd of February, 2018 09:03:35 AM
Is it appropriate to only report 43249 and 43245 in this case since the biopsies are of the stomach and duodenum? The pylorus appeared stenotic, barely admitting the scope. The first and second portion of the duodenum appeared normal. I took biopsies of the duodenum, and stomach. I passed a TTS pyloric balloon dilator through the suction channel of the endoscope while the endoscope was in the lumen of the duodenum. I gradually pulled back on the endoscope as the dilator entered the lumen of the duodenum. I could see that the balloon spanned the pylorus. I dilated the balloon from 12mm to 13.5mm to 15mm each for sixty seconds. After the procedure I inspected the pylorus and saw no complications. I also saw that the lumen was more widely patent. I then dilated the distal esophagus with a through the scope balloon. I dilated from 15mm to 16.5mm to 18 mm.
SuperCoder Answered Mon 05th of February, 2018 05:14:40 AM

Hello

Yes both CPTs 43249 and 43245 would be the appropriate CPTs as per the above scenario. Biopsies will be inclusive to these codes.

HOPE THIS HELPS!

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