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Esophagoscopy is a medical procedure that involves the use of a flexible endoscope to visually examine the esophagus, which is the tube that connects the throat to the stomach. This procedure is performed transorally, meaning the endoscope is inserted through the mouth. During the esophagoscopy, the physician can assess various structures, including the velopharyngeal closure, the base of the tongue, and the hypopharynx. Vocal cord motion is also observed, and the pharyngeal musculature is evaluated for any abnormalities. The endoscope is carefully advanced through the esophagus until it reaches the gastroesophageal junction, allowing for a thorough examination of the entire length of the esophagus. In the context of CPT® Code 43216, the procedure specifically includes the removal of tumors, polyps, or other lesions using hot biopsy forceps. This technique involves the use of insulated monopolar forceps that not only excise the tissue but also cauterize it simultaneously, which helps to minimize bleeding. The hot biopsy method is particularly effective for small polyps and the treatment of vascular ectasias. This procedure is critical for diagnosing and treating various esophageal conditions, ensuring that any abnormal growths are addressed promptly and effectively.
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Esophagoscopy with the removal of tumors, polyps, or other lesions is indicated for various conditions that may affect the esophagus. The following are explicitly provided indications for this procedure:
The procedure of esophagoscopy with the removal of lesions involves several detailed steps:
Post-procedure care following esophagoscopy with lesion removal includes monitoring the patient for any immediate complications, such as bleeding or perforation. Patients may be advised to refrain from eating or drinking until the effects of sedation have worn off and the physician has confirmed that it is safe to resume normal activities. Follow-up appointments may be scheduled to discuss pathology results if biopsies were taken and to evaluate the patient's recovery. Additionally, patients should be informed about potential symptoms to watch for, such as difficulty swallowing or chest pain, which should prompt immediate medical attention.
| Short Descr | ESOPHAGOSCOPY LESION REMOVAL | Medium Descr | ESPHAGOSCOPY FLEX LESION REMOVAL HOT BX FORCEPS | Long Descr | Esophagoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps | 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 | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P8B - Endoscopy - upper gastrointestinal | MUE | 1 | CCS Clinical Classification | 93 - Other non-OR upper GI therapeutic procedures |
| 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. |
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| 2017-01-01 | Changed | Moderate (Conscious) Sedation flag removed. See new Moderate Sedation category. |
| 2015-01-01 | Changed | Description Changed |
| 2014-01-01 | Changed | Description Changed |
| 1994-01-01 | Added | First appearance in code book in 1994. |
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