Knowledge Base Article

Q:

Sometimes a physician may dilate more than one stricture during an endoscopy procedure. Should we code the dilation of each stricture?

A:

The answer depends on the patient’s insurance because CPT and the NCCI manual provide different coding instructions.

Effective January 2015, CPT guidance allows the reporting of each stricture dilated utilizing modifier 59. Parenthetical notes for CPT codes 43213, 45340, and 45386 state, “For transendoscopic balloon dilation of multiple strictures during the same session, report ‘code’ (43213, 45340, or 45386) with modifier 59 for each additional stricture dilated.”

The National Correct Coding Initiative (NCCI) Policy manual guidance applies to coding and billing for Medicare and Medicaid claims. The 2015 NCCI manual update includes this instruction concerning dilation of multiple strictures:

“Gastrointestinal endoscopy CPT codes describing dilation of stricture(s) (e.g., CPT codes 43213, 45340, 45386) include dilation of all strictures dilated during the endoscopic procedure. These codes should not be reported with more than one (1) unit of service if more than one stricture is dilated.”

Other insurers may choose to follow some of the NCCI coding guidance. Check with the payer to determine their policy regarding these instructions.