© Copyright 2025 American Medical Association. All rights reserved.
The procedure described by CPT® Code 43453 involves the dilation of the esophagus using a guide wire. This technique is utilized when a physician needs to treat an esophageal stricture, which is a narrowing of the esophagus that can occur due to various conditions such as esophageal reflux, benign or malignant lesions, or other injuries and diseases affecting the esophagus. The dilation process is performed without direct visualization of the esophagus, meaning that the physician does not use an endoscope to see the esophagus during the procedure. Instead, the physician employs a series of progressively larger rigid rubber tubes, known as sounds or bougies, which are inserted through the mouth and advanced down into the esophagus to widen the narrowed area. The use of a guide wire in this procedure (as opposed to unguided methods) allows for more precise placement of the dilating instruments. Additionally, it is important to note that a separate esophagram may be conducted prior to the dilation to assess the location and severity of the stricture, and fluoroscopy may be utilized during the procedure to aid in the dilation process.
© Copyright 2025 Coding Ahead. All rights reserved.
The dilation of the esophagus using CPT® Code 43453 is indicated for the treatment of esophageal stricture, which can arise from various underlying conditions. The specific indications for this procedure include:
The procedure for dilation of the esophagus over a guide wire involves several key steps, which are detailed as follows:
Following the dilation procedure, patients may be monitored for any immediate complications or adverse reactions. It is common for patients to experience some discomfort or a sensation of fullness in the throat, which typically resolves shortly after the procedure. The physician may provide specific post-procedure care instructions, including dietary modifications or recommendations for follow-up evaluations. Patients are often advised to avoid certain foods or activities for a brief period to allow the esophagus to heal properly. Additionally, any necessary follow-up imaging or assessments may be scheduled to evaluate the effectiveness of the dilation and to monitor for potential recurrence of the stricture.
| Short Descr | DILATE ESOPHAGUS | Medium Descr | DILATION ESOPHAGUS GUIDE WIRE | Long Descr | Dilation of esophagus, over guide wire | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple 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. | 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) | P5E - Ambulatory procedures - other | MUE | 1 | CCS Clinical Classification | 69 - Esophageal dilatation |
| 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. | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | 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. | 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.) | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | CR | Catastrophe/disaster related | GC | This service has been performed in part by a resident under the direction of a teaching physician | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | GW | Service not related to the hospice patient's terminal condition | SG | Ambulatory surgical center (asc) facility service | X4 | Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period | 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. |
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.