© Copyright 2025 American Medical Association. All rights reserved.
Esophagogastroduodenoscopy (EGD) is a diagnostic and therapeutic procedure that involves the use of a flexible endoscope to visualize the upper gastrointestinal tract, including the esophagus, stomach, and duodenum. This procedure is specifically performed for the dilation of the esophagus using a balloon that is 30 mm in diameter or larger. The primary purpose of esophageal dilation is to treat strictures, which are areas of narrowing in the esophagus that can impede the passage of food and liquids. Strictures may arise from various conditions, including reflux esophagitis, which leads to inflammation and scarring of the esophagus; Schatzki's ring, a benign fibrous tissue formation; congenital esophageal atresia, a birth defect; or malignant diseases that cause obstruction. During the procedure, the endoscope is introduced transorally, allowing for a thorough examination of the velopharyngeal closure, base of the tongue, and hypopharynx. The vocal cords and pharyngeal musculature are also assessed. As the endoscope is advanced through the esophagus, any abnormalities are documented, and the procedure may include fluoroscopic guidance to assist in the dilation process. The balloon catheter is carefully positioned at the site of the stricture, inflated to the appropriate pressure, and then deflated and removed after a brief period, ensuring that the dilation is effective and that no injuries have occurred during the procedure.
© Copyright 2025 Coding Ahead. All rights reserved.
Esophagogastroduodenoscopy with dilation of the esophagus is indicated for the following conditions:
The procedure begins with the patient being positioned appropriately, and sedation may be administered to ensure comfort. The flexible endoscope is then introduced through the mouth and advanced into the esophagus. The velopharyngeal closure, base of the tongue, and hypopharynx are carefully examined to assess any abnormalities. Vocal cord motion is observed, and the pharyngeal musculature is evaluated. As the endoscope reaches the cricopharyngeus muscle, the patient may be instructed to burp or swallow to facilitate the passage of the scope. The endoscope is then advanced along the entire length of the esophagus, allowing for a thorough inspection of the esophageal lining and identification of any strictures. Once the endoscope reaches the stomach, it is advanced through the pylorus into the duodenum, where the mucosal surfaces are inspected. After completing the examination, the endoscope is withdrawn, and the pylorus and stomach mucosa are also evaluated. To perform the dilation, a deflated balloon catheter is advanced through the instrument channel of the endoscope to the site of the stricture, guided by fluoroscopy if necessary. The balloon is inflated to the optimal pressure, as determined by a pressure gauge, and is maintained in this inflated state for a duration of 30 seconds to 2 minutes. Following this, the balloon is deflated and removed. The area of stricture is then re-evaluated using the endoscope to confirm the success of the dilation and to check for any potential injuries resulting from the procedure.
After the esophagogastroduodenoscopy with dilation, patients are typically monitored for a short period to ensure there are no immediate complications. It is common for patients to experience some throat discomfort or mild soreness following the procedure, which usually resolves quickly. Patients may be advised to start with clear liquids and gradually progress to a regular diet as tolerated. Follow-up appointments may be scheduled to assess the effectiveness of the dilation and to monitor for any recurrence of symptoms. It is important for patients to report any unusual symptoms, such as severe pain, difficulty swallowing, or signs of bleeding, to their healthcare provider promptly.
| Short Descr | EGD BALLOON DIL ESOPH30 MM/> | Medium Descr | EGD ESOPHAGUS BALLOON DILATION 30 MM OR LARGER | Long Descr | Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed) | 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 | 43235 Esophagogastroduodenoscopy, 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 |
| GC | This service has been performed in part by a resident under the direction of a teaching physician | 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). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 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. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | CR | Catastrophe/disaster related | GW | Service not related to the hospice patient's terminal condition | PT | Colorectal cancer screening test; converted to diagnostic test or other procedure | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | SG | Ambulatory surgical center (asc) facility service | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
|
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.