2025 CPT code 43450
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Digestive System Surgery Feed
Dilation of the esophagus using an unguided bougie or sound, involving single or multiple passes.
Modifiers may be applicable depending on the circumstances of the procedure. Refer to CPT guidelines and payer specific rules.
Esophageal dilation is medically necessary when there is significant esophageal stricture causing dysphagia (difficulty swallowing) that impacts the patient’s nutrition, hydration, and overall well-being.Medical necessity should be established based on clinical findings such as endoscopy, barium swallow studies and patient symptoms.
The physician performs the esophageal dilation using a bougie or sound. Pre and post-procedure endoscopy may be done for assessment, but the dilation itself is performed without the assistance of an endoscope. The physician is responsible for preparing the patient, performing the dilation, monitoring the patient during and after the procedure, and assessing the outcome.
In simple words: The doctor widens a narrowed part of the food pipe (esophagus) using a thin, flexible tube to make swallowing easier. This may involve inserting the tube multiple times, increasing the tube size each time.
This procedure involves the dilation of a narrowed section of the esophagus (esophageal stricture) to improve swallowing.The physician uses a bougie or sound, a slender, flexible, solid or hollow tubular instrument, to dilate the stricture. The instrument may be passed multiple times, gradually increasing the diameter until sufficient dilation is achieved.An endoscope may be used for pre- and post-dilation examination, but the dilation itself is performed without endoscopic guidance.
Example 1: A 60-year-old female patient presents with dysphagia (difficulty swallowing) due to a peptic stricture caused by chronic GERD.The physician performs an esophageal dilation using a bougie, achieving sufficient dilation after three passes.A pre- and post-dilation esophagoscopy shows resolution of the stricture., A 45-year-old male patient with a history of achalasia undergoes esophageal dilation with a bougie.The physician performs multiple passes with increasing diameter bougies until adequate dilation is achieved.The patient reports improved swallowing post-procedure., A 72-year-old female presents with dysphagia secondary to a Schatzki ring. The physician performs an esophageal dilation with a bougie.The procedure is successful in relieving the dysphagia.
* Detailed history and physical examination documenting the patient's symptoms and the indication for esophageal dilation.* Pre-procedure endoscopy report (if performed).* Documentation of the procedure itself, including the type and size of the bougie or sound used, number of passes, and any complications.* Post-procedure endoscopy report (if performed).* Documentation of any medications used for sedation or anesthesia.* Patient's response to the procedure, including immediate post-procedure symptoms.* Follow-up plan.
** The information provided is for reference only.Always consult the most current CPT manual and payer guidelines for accurate coding and reimbursement.
- Revenue Code: P5E (AMBULATORY PROCEDURES - OTHER)
- RVU: Information not available in source. Refer to CMS guidelines for current RVUs.
- Global Days: Information not available in the source.The global period will depend on payer and local policies.It's advisable to check with the specific payer for details.
- Payment Status: Active
- Modifier TC rule: Information not available in the source.
- Fee Schedule: Information not available in the source. Fee schedules vary by payer and location.Consult the relevant payer for specific information.
- Specialties:Gastroenterology, General Surgery
- Place of Service:Office, Ambulatory Surgical Center, Hospital Outpatient Department