A GERD treatment, Esophagogastric fundoplasty involves wrapping the upper portion of the stomach (the fundus) around the esophagus to strengthen the valve between the esophagus and stomach, thereby inhibiting acid from backing up into the esophagus.
CPT(R) 2016 introduces 43210 Esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed for partial or complete esophagogastric fundoplasty when performed via flexible, transoral endoscope.
As per CPT(R), do not report 43210 with:
43180 Esophagoscopy, rigid, transoral with diverticulectomy of hypopharynx or cervical esophagus (eg, Zenker?s diverticulum), with cricopharyngeal myotomy, includes use of telescope or operating microscope and repair, when performed
43191 Esophagoscopy, rigid, transoral; diagnostic, including collection of specimen(s) by brushing or washing when performed (separate procedure)
43197 Esophagoscopy, flexible, transnasal; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
43200 Esophagoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
43235 Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
The most common condition treated with a transoral esophagogastric fundoplasty is gastroesophageal reflux(GERD).
In ICD-10-CM there are a few options when reporting GERD. If the patient has GERD without esophagitis (inflammation of the esophagus) K21.9 Gastro-esophageal reflux disease without esophagitis is reported. If the patient has GERD and esophagitis, K21.0 Gastro-esophageal reflux disease with esophagitis is reported. There is no longer a need to report esophagitis as an additional code with the creation of the combination code.
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