© Copyright 2025 American Medical Association. All rights reserved.
Esophagoscopy, flexible, transoral, with endoscopic mucosal resection, is a specialized medical procedure that involves the use of a flexible endoscope to visualize and treat lesions within the esophagus. This procedure is particularly significant for addressing dysplastic or precancerous lesions, as well as small, early-stage cancerous lesions that are confined to the mucosal layer of the esophagus. The flexible endoscope is introduced through the mouth and carefully advanced into the esophagus, allowing the physician to reach the specific area where the lesion is located. During the procedure, the borders of the lesion are marked using electrocautery, which helps delineate the area for removal. To facilitate the excision, diluted adrenaline is injected into the submucosal layer surrounding the lesion, effectively lifting the mucosal layer and creating a separation from the underlying muscle tissue. This technique enhances the visibility and accessibility of the lesion. A snare equipped with a suction cup is then employed to grasp and excise the lesion, which is subsequently captured for analysis. After the lesion is removed, the endoscope is withdrawn, and a thorough examination of the entire esophagus is conducted to ensure no additional lesions are present. The excised tissue is sent for pathological examination, which is reported separately, providing critical information for further management and treatment decisions.
© Copyright 2025 Coding Ahead. All rights reserved.
Esophagoscopy with endoscopic mucosal resection is indicated for the following conditions:
The procedure involves several critical steps to ensure effective treatment of the lesion:
Post-procedure care involves monitoring the patient for any immediate complications, such as bleeding or perforation. Patients may experience some discomfort or throat irritation following the procedure, which is typically manageable with standard analgesics. It is essential to provide instructions regarding dietary modifications and activity restrictions during the recovery period. Additionally, the excised tissue is sent for pathological examination, and the results will guide further treatment decisions and follow-up care.
| Short Descr | ESOPHAGOSCOP MUCOSAL RESECT | Medium Descr | ESOPHAGOSCOPY FLEXIBLE TRANSORAL MUCOSAL RESEXN | Long Descr | Esophagoscopy, flexible, transoral; with endoscopic mucosal resection | 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 | 43200 Esophagoscopy, flexible, transoral; 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 | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P8B - Endoscopy - upper gastrointestinal | MUE | 1 |
| 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. | GC | This service has been performed in part by a resident under the direction of a teaching physician | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2017-01-01 | Changed | Moderate (Conscious) Sedation flag removed. See new Moderate Sedation category. |
| 2014-01-01 | Added | Added |
Get instant expert-level medical coding assistance.