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Esophagoscopy, flexible, transnasal, is a medical procedure that involves the use of a flexible endoscope to visualize the esophagus. This procedure is performed by introducing the endoscope through the patient's nose, allowing for a less invasive approach compared to traditional methods. The flexible endoscope is advanced into the esophagus, enabling the physician to examine critical areas such as the velopharyngeal closure, the base of the tongue, and the hypopharynx. During the procedure, vocal cord motion is assessed, and the pharyngeal musculature is evaluated for any abnormalities. As the endoscope reaches the cricopharyngeus, the patient may be instructed to burp or swallow, which aids in the smooth passage of the scope into the esophagus. The endoscope is then advanced along the entire length of the esophagus until it reaches the gastroesophageal junction. Any abnormalities observed during this examination are carefully noted. After the thorough inspection, the endoscope is withdrawn, allowing for a complete examination of the esophagus's circumference. If any suspicious areas are identified, biopsy forceps are introduced through the endoscope's biopsy channel. The forceps are opened to capture a tissue sample, which is then removed for further analysis. This procedure allows for the collection of one or more tissue samples, which are sent for laboratory analysis to aid in diagnosis and treatment planning.
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Esophagoscopy, flexible, transnasal, with biopsy is indicated for various clinical scenarios where direct visualization and tissue sampling of the esophagus are necessary. The following conditions may warrant this procedure:
The procedure of flexible transnasal esophagoscopy with biopsy involves several key steps that ensure thorough examination and accurate tissue sampling.
After the flexible transnasal esophagoscopy with biopsy, patients are typically monitored for a short period to ensure there are no immediate complications. It is common for patients to experience mild throat discomfort or a sensation of fullness, which usually resolves quickly. Patients may be advised to avoid eating or drinking until the effects of any local anesthesia have worn off. Additionally, they should be informed about potential symptoms to watch for, such as excessive bleeding or difficulty swallowing, and instructed to contact their healthcare provider if these occur. The results of the biopsy will be communicated to the patient once they are available, and follow-up care will be discussed based on the findings.
| Short Descr | ESOPHAGOSC FLEX TRNSN BIOPSY | Medium Descr | ESOPHAGOSCOPY FLEXIBLE TRANSNASAL WITH BIOPSY | Long Descr | Esophagoscopy, flexible, transnasal; with biopsy, single or multiple | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 3 - Special payment adjustment rules for multiple endoscopic procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Endoscopic Base Code | 43197 Esophagoscopy, flexible, transnasal; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Procedure or Service, Multiple Reduction Applies | ASC Payment Indicator | Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on MPFS nonfacility PE RVUs. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P8B - Endoscopy - upper gastrointestinal | MUE | 1 |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | CR | Catastrophe/disaster related | GC | This service has been performed in part by a resident under the direction of a teaching physician | GW | Service not related to the hospice patient's terminal condition | GZ | Item or service expected to be denied as not reasonable and necessary |
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