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CPT®
43456

CPT® Code 43456
Deleted

Code deleted, see 43213

Official Description

Dilation of esophagus, by balloon or dilator, retrograde

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 43456 involves the dilation of the esophagus using a retrograde approach, which is particularly indicated when traditional endoscopic access through the mouth is not feasible. This situation may arise due to various conditions, such as injuries or obstructions of the trachea, which can occur in cases of burns or malignancies. The retrograde approach necessitates an incision in the abdomen, allowing access to the stomach. Once the stomach is incised, a balloon catheter is carefully advanced to the area of the esophagus that is narrowed or obstructed. The balloon is then inflated to widen the stricture, and this inflation may be repeated multiple times to achieve the desired diameter. Alternatively, a series of progressively larger tubes can be utilized to gradually dilate the stricture. After the procedure, the stomach incision is sutured closed, followed by the closure of the abdominal incision in layers, ensuring proper healing and recovery.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The dilation of the esophagus by balloon or dilator using a retrograde approach is indicated for specific conditions that prevent endoscopic access through the mouth. These indications include:

  • Tracheal Injury - Situations where the trachea is injured, making it unsafe or impossible to perform an endoscopic procedure through the oral cavity.
  • Tracheal Obstruction - Conditions that cause obstruction of the trachea, such as tumors or other masses that may impede access to the esophagus.
  • Malignancy - The presence of cancerous growths that may lead to strictures or narrowing of the esophagus, necessitating dilation to restore passage.
  • Burns - Thermal injuries that may result in scarring or narrowing of the esophagus, requiring intervention to alleviate obstruction.

2. Procedure

The procedure for dilation of the esophagus by balloon or dilator via a retrograde approach involves several critical steps:

  • Step 1: Incision in the Abdomen - The procedure begins with a surgical incision made in the abdominal wall to gain access to the stomach. This step is essential for the retrograde approach, as it allows the surgeon to navigate to the esophagus from below.
  • Step 2: Incision of the Stomach - Following the abdominal incision, the stomach is incised to facilitate the advancement of the balloon catheter. This incision must be carefully performed to minimize trauma to the surrounding tissues.
  • Step 3: Advancement of the Balloon Catheter - A balloon catheter is then advanced through the incision in the stomach to the site of the esophageal stricture or narrowing. This step requires precision to ensure that the catheter reaches the correct location.
  • Step 4: Inflation of the Balloon - Once positioned at the stricture, the balloon is inflated. This inflation is crucial as it exerts pressure on the narrowed segment of the esophagus, gradually widening it. The balloon remains inflated for a short period to achieve the desired dilation.
  • Step 5: Deflation and Repetition - After the initial inflation, the balloon is deflated. This inflation and deflation process may be repeated several times to ensure that the esophagus is dilated to the appropriate diameter.
  • Step 6: Alternative Dilation Method - As an alternative to balloon dilation, a series of tubes with increasing diameters may be inserted through the stomach to the narrowed segment of the esophagus. This method allows for gradual dilation of the stricture.
  • Step 7: Closure of the Stomach Incision - Once the desired diameter of the esophagus is achieved, the incision in the stomach is closed. This closure is performed meticulously to prevent complications.
  • Step 8: Closure of the Abdominal Incision - Finally, the abdominal incision is closed in layers, ensuring proper healing and minimizing the risk of infection or other postoperative complications.

3. Post-Procedure

Post-procedure care following the dilation of the esophagus includes monitoring for any complications that may arise from the surgical intervention. Patients may be observed for signs of infection, bleeding, or any adverse reactions to anesthesia. Recovery time can vary, but patients are typically advised to follow a specific diet and may need to avoid certain foods that could irritate the esophagus during the healing process. Follow-up appointments are essential to assess the success of the dilation and to determine if further interventions are necessary.
Short Descr DILATE ESOPHAGUS
Medium Descr DILAT ESOPHAGUS BALLOON/DILATOR RETROGRADE
Long Descr Dilation of esophagus, by balloon or dilator, retrograde
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 Procedure or Service, Multiple Reduction Applies
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) none
MUE Not applicable/unspecified.
CCS Clinical Classification 69 - Esophageal dilatation
Date
Action
Notes
2014-01-01 Deleted Code deleted, see 43213
Pre-1990 Added Code added.
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