Dilation of a sleeve gastrectomy Coding Clinic for HCPCS – Second Quarter 2014 Page: 3

Demonstrate the use of official coding references; and presenting explanations of concepts or methods. Explain why this resource would be beneficial to a coder. Elaborate on the procedure. (this is what you will be doing…read the article below)

QUESTION 4

What would the correct code assignment be for the dilation of a sleeve gastrectomy? Some of our coders have assigned CPT code 43245 however; the other coders feel that this code is reported for dilation of a gastric outlet so it doesn’t seem to be the correct code to use.

Would CPT code 43999 be the best code to describe the dilation of a gastric sleeve procedure via an esophagogastroduodenoscopy (EGD) approach?

ANSWER

Based on the operative note, the scope was

passed into the gastric sleeve … and an area was noted to be stenotic

… . The stenosis was dilated without difficulty. Therefore, report CPT

code 43245, Esophagogastroduodenoscopy, flexible, transoral; with dilation of gastric/duodenal stricture(s) (e.g., balloon, bougie),

for the gastric sleeve dilation procedure performed. Please note, CPT

code 43245 is not limited to the dilation of gastric outlet.

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