43248

🧬CPT Code 43248 — EGD with Insertion of Guide Wire Followed by Dilation of Esophagus Over Guide Wire

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📋 Quick Reference

Field	Detail
CPT Code	43248
Full Descriptor	Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by dilation of esophagus over guide wire
Short Descriptor	EGD w/ guide wire dilation of esophagus
Category	Upper GI Endoscopy — Therapeutic
Specialty	Gastroenterology · General Surgery · Thoracic Surgery · Otolaryngology
Global Period	000 — Zero Days
wRVU (Work)	~2.95 CMS PFS 2026 — verify against current CMS RVU download file
Assistant Payable	❌ No
Bilateral Concept	❌ Not applicable
Moderate Sedation	✅ Bundled — do not separately report 99152-99153
Multiple Procedure Reduction	✅ Yes — 50% reduction applies when billed with additional endoscopic procedures same session
Facility / Non-Facility	Both applicable — RVU totals differ per CMS PFS
Multiple Dilations, Same Session	Only one unit of 43248 reportable per session regardless of number of passes

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🔬 Procedure Description

CPT 43248 describes a flexible, transoral esophagogastroduodenoscopy (EGD) during which a guide wire is first inserted through or alongside the endoscope, followed by passage of a dilating instrument over that wire to mechanically widen a stenotic, strictured, or narrowed segment of the esophagus.

Distinguishing Feature: The Guide Wire

The defining characteristic that sets 43248 apart from other EGD dilation codes is the mandatory use of a guide wire. The endoscope is used to:

1. Directly visualize the stricture or narrowing
2. Place a flexible guide wire through the stricture under endoscopic (and sometimes fluoroscopic) guidance
3. Allow passage of a dilating instrument over the wire while maintaining positional control and reducing perforation risk

This technique provides superior safety compared to blind or scope-guided dilation alone, particularly in:

• Complex, tight, or tortuous strictures
• Malignant strictures with irregular lumens
• Post-surgical or radiation-induced narrowing where anatomy is distorted
• Lesions where the true lumen may be difficult to navigate

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Procedural Sequence — Step by Step

1. Patient Preparation — Standard upper endoscopy preparation including appropriate fasting, topical pharyngeal anesthesia (e.g., benzocaine spray), IV access, monitoring, and moderate sedation/analgesia administered by the performing endoscopist (bundled) or independent provider.

2. Scope Introduction & Advancement — A flexible video endoscope is passed transorally through the oropharynx, esophagus, stomach, and into the duodenum as clinically necessary. Full diagnostic survey of the upper GI tract is performed and documented. This diagnostic component is inherent to 43248 and is not separately reportable.

3. Stricture Identification & Characterization — The endoscopist identifies and characterizes the stricture or stenosis:

   • Location (upper, mid, lower esophagus; GEJ; anastomotic)
   • Length and severity of narrowing
   • Mucosal appearance (inflammatory vs. malignant vs. fibrotic)
   • Luminal diameter estimate (e.g., < 9 mm = significant dysphagia threshold)

4. Guide Wire Placement — A flexible-tipped guide wire (most commonly a 0.035-inch or 0.025-inch Savary guide wire or a Terumo-type wire) is passed through the accessory channel of the endoscope and advanced through the stricture under direct endoscopic visualization, often with fluoroscopic confirmation of wire position in the stomach or duodenum. The scope is then withdrawn over the wire, maintaining wire position.

5. Bougie/Dilator Passage — A wire-guided dilator is then passed over the guide wire:

   • Savary-Gilliard polyvinyl dilators — tapered, graded in French sizes (15 Fr to 60 Fr = 5 mm to 20 mm), most commonly used

   • American Dilators (Bard) — similar polyvinyl wire-guided system

   • Wire-guided balloon-on-wire systems — some operators use wire-guided through-the-scope (TTS) balloons (note: if a balloon dilator is used through the scope, see 43249 distinction below)

   ⚠️ Critical Coding Note — 43248 vs. 43249: 43248 = wire-guided bougie/dilator (Savary-Gilliard type); the scope is typically withdrawn before dilators are passed over the wire. 43249 = balloon dilation through the scope (TTS balloon, < 30 mm diameter), scope remains in place. These codes are mutually exclusive and selection depends on the technique documented in the operative report.

6. Progressive Dilation (“Rule of Three”) — Dilators of progressively larger diameter are advanced over the wire in sequence. The traditional “Rule of Three” guideline suggests advancing no more than three dilator sizes past initial resistance per session to minimize perforation risk, though clinical judgment governs actual practice. Typically:

   • Start 1-2 dilator sizes below estimated stricture diameter
   • Progress in 1 Fr increments through resistance
   • Target lumen diameter is typically ≥ 15 mm (45 Fr) for functional swallowing

7. Wire Removal & Scope Re-introduction — After dilation is complete, the guide wire is removed. The endoscope is often re-introduced to:

   • Assess post-dilation result (mucosal tears, bleeding)
   • Confirm adequate luminal diameter
   • Obtain biopsies if indicated (see bundling notes below)
   • Place a stent if planned (requires separate CPT coding)

8. Procedure Documentation — Operative report should include:

   • Indication and pre-procedure diagnosis
   • Pre-dilation luminal diameter estimate
   • Type and size of wire used
   • Dilator system used and sizes passed
   • Post-dilation luminal diameter and mucosal assessment
   • Any complications (mucosal tear, hemorrhage, suspected perforation)
   • Tolerance and patient condition post-procedure

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✅ Includes (Bundled Components)

The following are inherent to 43248 and must not be separately reported:

• Full diagnostic upper endoscopy (esophagus, stomach, duodenum/proximal jejunum) — same session
• Guide wire insertion and manipulation
• All passes of the dilating instrument during the same session — regardless of how many dilators are passed, 43248 is reported once
• Fluoroscopic guidance that is incidentally used during the procedure (in most payer policies — verify MAC LCD for separate fluoroscopy billing eligibility)
• Moderate sedation/conscious sedation administered by the performing endoscopist
• Standard photographic documentation
• Post-dilation endoscopic assessment of the treated segment if performed as part of the same operative session

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❌ Excludes / Mutually Exclusive Codes

Code	Description	Reason Excluded
43235	Diagnostic EGD	Bundled — inherent to all therapeutic EGD codes per NCCI
43249	EGD with balloon dilation of esophagus (< 30 mm)	Mutually exclusive — different dilation technique (TTS balloon); cannot bill both for the same session on the same stricture
43450	Dilation of esophagus, without endoscopy, by unguided sound or bougie	Non-endoscopic/blind technique; cannot combine with 43248
43453	Dilation of esophagus over guide wire	Non-endoscopic wire-guided dilation (fluoroscopy only, no flexible endoscope); distinct from 43248 which requires endoscopic visualization and guide wire placement
74360	Dilation of stricture — radiologic guidance	Do not additionally report fluoroscopy bundled in the endoscopic session unless MAC LCD specifically allows it
99152 / 99153	Moderate sedation services	Bundled; separately billable only when performed by an independent provider
76000	Fluoroscopy	Generally bundled — confirm with payer-specific policy and MAC LCD
43226	EGD with insertion of guide wire with subsequent passage of dilator without endoscopic visualization	Codes 43226 is for a non-visualization technique — do not confuse with 43248 which requires direct endoscopic visualization

⚠️ Biopsies Taken at Same Session: If biopsies are obtained at the same site as the dilation (e.g., biopsying the stricture), the biopsy code (e.g., 43239 — injection; or biopsy-specific codes like 43202, 43239) is generally bundled per NCCI. However, if a separate, distinct lesion is biopsied (e.g., gastric lesion biopsied while treating an esophageal stricture), modifier -59 or -XU may support separate billing with documentation. Always verify current NCCI edits.

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🌳 Code Tree — EGD Family (Esophageal Dilation Subset)

43235 ─── Diagnostic EGD (BASE CODE — diagnostic component inherent to all therapeutic EGDs)
│
│  ── Esophageal Dilation Codes ──
│
├── 43248 ─── EGD with guide wire insertion + dilation over guide wire (Savary-type)  ◀ THIS CODE
│             · Scope used for wire placement; dilators passed after scope withdrawal
│             · Wire-guided polyvinyl/tapered bougie technique
│
├── 43249 ─── EGD with balloon dilation of esophagus (< 30 mm diameter)
│             · Through-the-scope (TTS) balloon dilator
│             · Scope remains in place during dilation
│             · Same session, same stricture → mutually exclusive with 43248
│
├── 43245 ─── EGD with dilation of gastric/duodenal stenosis
│             · Target: pyloric channel, gastric outlet, duodenal stenosis
│             · NOT for esophageal dilation
│
│  ── Related Non-Endoscopic Dilation ──
│
├── 43450 ─── Dilation of esophagus, by unguided sound or bougie (NO endoscopy)
│             · Blind technique — no guide wire, no endoscope
│             · Used for simple/recurrent strictures in stable patients
│
├── 43453 ─── Dilation of esophagus over guide wire (NO flexible endoscope)
│             · Wire placed fluoroscopically; dilation without concurrent endoscopy
│             · Distinguished from 43248 by absence of flexible endoscopic visualization
│
│  ── EGD with Additional/Combined Procedures ──
│
├── 43239 ─── EGD with injection, other than sclerotherapy (e.g., intralesional steroid injection into stricture)
│             · Steroid injection into stricture may be performed with dilation — NCCI edits apply
│
└── 43270 ─── EGD with ablation of tumor(s)/polyp(s)/other lesions (not amenable to removal)
              · Ablation of malignant stricture prior to or following dilation — separate procedure rules apply

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🏷️ Associated ICD-10-CM Codes

Primary Diagnosis — Benign Esophageal Stricture / Dysphagia

ICD-10-CM	Description	HCC (v28)	Notes
K22.2	Esophageal obstruction	❌ No HCC	Most common benign indication; includes stricture, stenosis, compression
K22.10	Ulcer of esophagus without bleeding	❌ No HCC	Peptic ulcer-related stricture if documented
K22.11	Ulcer of esophagus with bleeding	❌ No HCC	Active hemorrhage from ulcerated stricture
K22.4	Dyskinesia of esophagus	❌ No HCC	Diffuse esophageal spasm, nutcracker esophagus, corkscrew esophagus
K22.8	Other specified diseases of esophagus	❌ No HCC	Residual or NOS stricture not elsewhere classifiable
K22.9	Disease of esophagus, unspecified	❌ No HCC	Use only when no specificity is available; query physician
K20.00	Eosinophilic esophagitis without bleeding	❌ No HCC	EoE-related stricture/narrowing — increasingly common indication
K20.01	Eosinophilic esophagitis with bleeding	❌ No HCC	EoE with active hemorrhage
K20.80	Other esophagitis without bleeding	❌ No HCC	Caustic, infectious, radiation-related esophagitis
K20.81	Other esophagitis with bleeding	❌ No HCC
Q39.3	Congenital stenosis and stricture of esophagus	❌ No HCC	Pediatric/congenital stricture — confirm patient age

Gastroesophageal Reflux / Post-inflammatory Stricture

ICD-10-CM	Description	HCC (v28)	Notes
K21.00	GERD with esophagitis without bleeding	❌ No HCC	Peptic/reflux stricture — very common indication
K21.01	GERD with esophagitis with bleeding	❌ No HCC
K21.9	GERD without esophagitis	❌ No HCC	Use when stricture related to GERD but no active esophagitis documented

Post-Surgical / Anastomotic Stricture

ICD-10-CM	Description	HCC (v28)	Notes
K91.89	Other postprocedural complications and disorders of digestive system	❌ No HCC	Anastomotic stricture s/p esophagectomy, sleeve gastrectomy, gastric bypass, fundoplication — most appropriate code
K91.30	Postprocedural intestinal obstruction, unspecified	❌ No HCC	When obstruction physiology is documented
T85.518A	Breakdown (mechanical) of bile duct prosthesis, initial encounter	❌ No HCC	If prior stent placed and stent-related stricture is issue

Malignant Esophageal Stricture

ICD-10-CM	Description	HCC (v28)	HCC Category	Notes
C15.3	Malignant neoplasm of upper third of esophagus	✅ HCC 10	Solid Tumor & Metastasis	Capture laterality/location per documentation
C15.4	Malignant neoplasm of middle third of esophagus	✅ HCC 10	Solid Tumor & Metastasis
C15.5	Malignant neoplasm of lower third of esophagus	✅ HCC 10	Solid Tumor & Metastasis	Most common — adenocarcinoma at GEJ
C15.8	Malignant neoplasm of overlapping sites of esophagus	✅ HCC 10	Solid Tumor & Metastasis
C15.9	Malignant neoplasm of esophagus, unspecified	✅ HCC 10	Solid Tumor & Metastasis	Use only when location undocumented
C16.0	Malignant neoplasm of cardia (GEJ)	✅ HCC 10	Solid Tumor & Metastasis	Gastric cardia tumors causing esophageal obstruction
Z85.01	Personal history of malignant neoplasm of esophagus	❌ No HCC	—	History/surveillance only — no current malignancy

Radiation-Induced / Caustic Stricture

ICD-10-CM	Description	HCC (v28)	Notes
T66.XXXA	Radiation sickness, unspecified, initial encounter	❌ No HCC	Radiation-related esophageal injury — also use Y84.2 for external cause
K22.2	Esophageal obstruction	❌ No HCC	Primary code for radiation-induced stricture; add external cause
T28.1XXA	Burn of esophagus, initial encounter	❌ No HCC	Caustic ingestion stricture (lye, acid)
T28.1XXD	Burn of esophagus, subsequent encounter	❌ No HCC	Subsequent dilation sessions for caustic stricture

Dysphagia Symptom Codes (When Etiology Established, Code Etiology First)

ICD-10-CM	Description	HCC (v28)	Notes
R13.10	Dysphagia, unspecified	❌ No HCC	Symptom code — use only if no etiology established
R13.11	Dysphagia, oral phase	❌ No HCC
R13.12	Dysphagia, oropharyngeal phase	❌ No HCC
R13.13	Dysphagia, pharyngeal phase	❌ No HCC
R13.14	Dysphagia, pharyngoesophageal phase	❌ No HCC
R13.19	Other dysphagia	❌ No HCC	Includes esophageal phase dysphagia when more specific

HCC Mapping Notes (CMS v28 Model)

💡 HCC Capture Opportunity — Malignant Strictures: When dilation is performed for a malignant esophageal stricture (esophageal cancer, gastric cardia tumor), the malignancy codes (C15.x, C16.0) map to HCC 10 (Solid Tumor & Metastasis) under v28. This is a high-weight HCC. Additionally, if the patient has a history of chemotherapy or radiation therapy as part of their cancer treatment, secondary codes for those encounters add important clinical context. Always query for:

• Current vs. historical malignancy (active treatment = current code; no active treatment/surveillance only = Z85.x)
• Metastatic disease if documented (C78.89 — secondary malignant neoplasm of other digestive organs)
• Nutritional status complications (dysphagia → malnutrition → E43 or E44.0 — these carry HCC 21 in v28)

Malnutrition HCC Alert: Severe or moderate protein-calorie malnutrition (E43, E44.0) resulting from dysphagia and inadequate oral intake maps to HCC 21 under v28 — a frequently missed HCC in GI/oncology patients. Query the physician when documentation supports it. ^{CMS HCC Model v28 Mappings · ICD-10-CM FY2026 Guidelines}

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🏥 MS-DRG Mapping (Inpatient Context)

Inpatient Coder Note: CPT codes are not used in the inpatient setting. The table below reflects MS-DRGs commonly assigned when the patient is admitted with a primary diagnosis driving the need for esophageal dilation. MS-DRG assignment is driven by ICD-10-CM and ICD-10-PCS codes. The ICD-10-PCS equivalent of 43248 is essential for accurate DRG grouping.

Esophageal / GI DRGs (MDC 06)

MS-DRG	Description	Typical GMLOS	Common Trigger
391	Esophagitis, Gastroenteritis & Misc Digestive Disorders w MCC	~4.8 days	Esophageal stricture + MCC (e.g., malnutrition, sepsis, respiratory failure)
392	Esophagitis, Gastroenteritis & Misc Digestive Disorders w/o MCC	~2.8 days	Esophageal stricture, benign — no significant comorbidities
377	GI Hemorrhage w MCC	~5.5 days	Stricture + active GI bleeding with MCC
378	GI Hemorrhage w CC	~3.5 days	Stricture + GI bleeding with CC
379	GI Hemorrhage w/o CC/MCC	~2.3 days	Uncomplicated GI hemorrhage

Oncologic / Esophageal Cancer DRGs (MDC 06 / MDC 17)

MS-DRG	Description	Typical GMLOS	Notes
374	Digestive Malignancy w MCC	~7.2 days	Malignant esophageal stricture w MCC
375	Digestive Malignancy w CC	~4.5 days	Esophageal cancer, palliative dilation with CC
376	Digestive Malignancy w/o CC/MCC	~2.8 days	Low-complexity malignant stricture dilation

Nutritional / Metabolic DRGs (MDC 10)

MS-DRG	Description	Typical GMLOS	Notes
640	Nutritional & Misc Metabolic Disorders w MCC	~4.8 days	Dysphagia → malnutrition is principal, dilation secondary
641	Nutritional & Misc Metabolic Disorders w/o MCC	~3.0 days

⚠️ DRG Optimization Tip: In patients admitted primarily for dysphagia and malnutrition secondary to esophageal stricture, consider whether the stricture (K22.2) or the malnutrition (E43) better represents the principal diagnosis per UHDDS guidelines. The two pathways group to different MDCs and different DRG weights. Document the clinical circumstances clearly and apply the UHDDS definition: “the condition established after study to be chiefly responsible for causing the admission.” Neither designation is inherently wrong — it must reflect the documented clinical reality. ^{UHDDS Definition · CMS MS-DRG Grouper FY2026}

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🔩 ICD-10-PCS Crosswalk (Inpatient Procedure Coding)

Root Operation: Dilation (7) — Expanding an orifice or lumen. This is the correct root operation for esophageal dilation regardless of technique.

PCS Table Reference: Section 0 · Body System D · Root Operation 7 (Dilation)

Character	Position	Value	Meaning
1 — Section	Medical & Surgical	0
2 — Body System	Gastrointestinal System	D
3 — Root Operation	Dilation	7
4 — Body Part	See options below
5 — Approach	Via Natural/Artificial Opening Endoscopic	8
6 — Device	Intraluminal Device or No Device	D or Z
7 — Qualifier	No Qualifier	Z

Body Part Options (Character 4)

Body Part Value	Description	When to Use
1	Upper Esophagus	Stricture above the aortic arch / upper thoracic
2	Middle Esophagus	Stricture at the level of the tracheal bifurcation / mid-thoracic
3	Lower Esophagus	Stricture in the lower thoracic/abdominal esophagus, GEJ
5	Esophagus	Use when stricture location spans multiple segments or is unspecified in documentation
6	Esophagus, Upper and Lower	Less commonly used; spans full esophagus involvement

Device Options (Character 6)

Device Value	Description	When to Use
D	Intraluminal Device	If a stent is placed during the same operative session
Z	No Device	Standard dilation only — no device left in place

Compiled ICD-10-PCS Codes

PCS Code	Full Description	Use When
0D758ZZ	Dilation of Esophagus, Via Natural/Artificial Opening Endoscopic, No Device	Dilation of esophagus, unspecified segment, no stent
0D718ZZ	Dilation of Upper Esophagus, Endoscopic, No Device	Upper esophageal stricture, no stent
0D728ZZ	Dilation of Middle Esophagus, Endoscopic, No Device	Mid-esophageal stricture, no stent
0D738ZZ	Dilation of Lower Esophagus, Endoscopic, No Device	Lower esophageal/GEJ stricture, no stent
0D758DZ	Dilation of Esophagus, Endoscopic, Intraluminal Device	Dilation + stent placement, esophagus (unspecified)
0D738DZ	Dilation of Lower Esophagus, Endoscopic, Intraluminal Device	Dilation + stent placement, lower esophagus/GEJ

💡 Inpatient Coding Note: If a stent is placed following dilation (e.g., esophageal stent for malignant obstruction), the device character changes to D (Intraluminal Device). The stent placement is included in the dilation PCS code — a separate PCS code for stent insertion is not required when it occurs during the same endoscopic session as dilation. However, if stent placement is the primary procedure and dilation was preparatory, the root operation is still Dilation with device D. ^{ICD-10-PCS Official Guidelines FY2026 · AHA Coding Clinic}

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🏷️ Applicable Modifiers

Modifier	Name	Application to 43248
-22	Increased Procedural Services	Severe/complex stricture requiring unusually extensive number of passes, difficult anatomy, radiation fibrosis, or significantly prolonged procedure time; attach operative report clearly documenting complexity
-52	Reduced Services	Procedure initiated but only partially completed (e.g., guide wire placed but dilation aborted due to patient instability before dilation was completed)
-53	Discontinued Procedure	Procedure terminated after sedation administered but before the key component (guide wire placement or dilation) began due to patient safety concerns
-59	Distinct Procedural Service	If a clearly separate, distinct GI procedure is performed at a different anatomic site during the same session (e.g., 43244 band ligation for esophageal varices — confirmed as unrelated to the stricture site); must have documentation of distinct indication and site
-XU	Unusual Non-Overlapping Service	CMS preferred alternative to -59 for distinct services; same documentation requirements apply
-47	Anesthesia by Surgeon	Rarely used; only when the performing endoscopist personally administers general anesthesia (not moderate sedation, which is always bundled)
-GC	Teaching Physician Service	Academic/teaching hospital setting where a resident participates under attending supervision; attending must document key portions and personal presence
-GE	Resident Service (Primary Care Exception)	Limited applicability for this procedure — verify Medicare rules
-RT / -LT	Right Side / Left Side	Not applicable — esophageal procedures are midline/not lateralized
-76	Repeat Procedure by Same Physician	Repeat dilation on same day or for repeat session; append when same endoscopist repeats the procedure; document clinical necessity clearly

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📝 Coding Examples

Example 1 — Benign Peptic Stricture, Reflux-Related, Outpatient

Scenario: A 67-year-old female with longstanding GERD and progressive dysphagia presents for elective outpatient EGD. Endoscopy reveals a tight peptic stricture in the lower esophagus at 38 cm, estimated lumen diameter ~8 mm. Guide wire is placed through the stricture under direct endoscopic visualization with fluoroscopic confirmation. Scope is withdrawn over the wire. Savary-Gilliard dilators are passed sequentially: 36 Fr, 40 Fr, and 45 Fr. Post-dilation lumen diameter approximately 15 mm. Patient tolerated well.

Professional / Outpatient Billing:

• 43248 — EGD with guide wire insertion and dilation of esophagus

ICD-10-CM:

• K22.2 — Esophageal obstruction (principal/primary)
• K21.00 — GERD with esophagitis without bleeding (secondary — underlying etiology)

ICD-10-PCS (if inpatient):

• 0D738ZZ — Dilation of Lower Esophagus, Via Natural/Artificial Opening Endoscopic, No Device

MS-DRG (if inpatient): 392 — Esophagitis, Gastroenteritis & Misc Digestive Disorders w/o MCC

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Example 2 — Eosinophilic Esophagitis (EoE) with Felinization and Stricture

Scenario: A 34-year-old male with known EoE presents for management of recurrent food impaction and progressive solid food dysphagia. EGD reveals characteristic trachealization/felinization of the esophagus, a proximal esophageal stricture estimated at 10 mm in diameter, and mucosal fragility. Guide wire placed; esophagus dilated with Savary dilators to 42 Fr (14 mm) with care taken to avoid mucosal rents. A longitudinal mucosal tear is noted post-dilation (expected in EoE — documented as procedure-related, no intervention required). Biopsies obtained of the proximal and distal esophagus for histologic confirmation.

Professional / Outpatient Billing:

• 43248 — EGD with guide wire insertion and dilation (primary)
• Note: Biopsies obtained at the same stricture site are bundled per NCCI; if biopsies are taken at a separately identifiable, distinct site for a distinct clinical reason, separate biopsy code may be supported with modifier 59/XU and documentation. Verify current NCCI edits and payer policy.

ICD-10-CM:

• K20.00 — Eosinophilic esophagitis without bleeding (primary)
• R13.19 — Other dysphagia (secondary symptom — optional if etiology captures the indication)

ICD-10-PCS (if inpatient):

• 0D718ZZ — Dilation of Upper Esophagus, Endoscopic, No Device (if upper esophageal stricture is primary site dilated)

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Example 3 — Malignant Esophageal Stricture, Palliative Dilation

Scenario: A 71-year-old male with unresectable adenocarcinoma of the lower esophagus/GEJ presents with severe dysphagia and 15 lb weight loss over 3 months. EGD demonstrates near-total obstruction of the lower esophagus with a friable, irregular malignant mass. Guide wire placed carefully through the stricture under endoscopic and fluoroscopic guidance. Dilation with Savary dilators to 42 Fr for palliative relief of dysphagia. An esophageal self-expanding metal stent (SEMS) is then deployed over the wire for sustained palliation.

Professional / Outpatient Billing:

• 43248 — EGD with guide wire insertion and dilation (dilation component)
• 43274 — EGD with placement of endoscopic stent (includes predilation) — if stent placement is the primary intent, 43274 may encompass both the dilation and stent deployment; verify with payer and operative documentation

⚠️ Coding Note: If the operative note documents both dilation AND stent placement as distinct, sequential, separately completed procedures, some payers allow both 43248 and 43274 with modifier 59. However, if 43274 is billed, it includes predilation — meaning dilation may be bundled. Consult current NCCI edits and your MAC’s LCD for esophageal stenting. When in doubt, query the billing provider and document the clinical distinction clearly.

ICD-10-CM:

• C15.5 — Malignant neoplasm of lower third of esophagus (principal — active primary malignancy)
• E43 — Unspecified severe protein-calorie malnutrition (secondary — if physician documents malnutrition; adds HCC 21)
• R13.19 — Other dysphagia (secondary symptom)

ICD-10-PCS (inpatient — dilation + stent):

• 0D738DZ — Dilation of Lower Esophagus, Endoscopic, Intraluminal Device (stent left in place)

MS-DRG: 374 — Digestive Malignancy w MCC (if malnutrition or another MCC documented)

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Example 4 — Post-Surgical Anastomotic Stricture After Esophagectomy

Scenario: A 58-year-old female, s/p Ivor Lewis esophagectomy 6 months prior for mid-esophageal squamous cell carcinoma, presents with worsening dysphagia to solids. EGD reveals a tight anastomotic stricture at the thoracic anastomosis site estimated at 7 mm. Guide wire placed through the stricture under direct visualization with fluoroscopic guidance. Savary dilators passed progressively to 45 Fr. Good post-dilation result with lumen diameter approximately 15 mm.

Professional / Outpatient Billing:

• 43248 — EGD with guide wire insertion and dilation

ICD-10-CM:

• K91.89 — Other postprocedural complications and disorders of digestive system (anastomotic stricture — principal)
• Z85.01 — Personal history of malignant neoplasm of esophagus (secondary — cancer is in history/remission; no current active malignancy)

ICD-10-PCS (if inpatient):

• 0D728ZZ — Dilation of Middle Esophagus, Endoscopic, No Device (thoracic anastomosis at mid-esophageal level)

MS-DRG: 391 or 392 depending on CC/MCC status

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Example 5 — Caustic Ingestion Stricture, Repeat Dilation (Subsequent Encounter)

Scenario: A 22-year-old patient with history of lye ingestion at age 12, resulting in a long-segment esophageal stricture. Presents for 4th repeat dilation session. EGD performed; guide wire placed; Savary dilation to 42 Fr. Procedure complicated by a small superficial mucosal tear without significant hemorrhage; procedure completed and patient monitored.

Professional / Outpatient Billing:

• 43248 — EGD with guide wire insertion and dilation (primary)

ICD-10-CM:

• T28.1XXD — Burn of esophagus, subsequent encounter (caustic burn stricture — “D” = subsequent encounter)
• K22.2 — Esophageal obstruction (secondary — the stricture itself)

ICD-10-PCS (if inpatient):

• 0D758ZZ — Dilation of Esophagus, Endoscopic, No Device

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Example 6 — Teaching Hospital, Resident Participation, Modifier GC

Scenario: Academic medical center; GI fellow performs EGD and guide wire insertion under direct supervision of attending gastroenterologist who is present for key portions of the procedure. Attending documents personal presence and key portions in the operative note.

Professional Billing:

• 43248-GC — Teaching physician attestation satisfies Medicare billing requirements; attending must document presence for key portions and supervision

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⚙️ Billing & Reimbursement Notes

• Medicare Coverage: No standalone NCD specifically governs esophageal dilation. Coverage is adjudicated by the MAC per applicable LCD (e.g., L33609 for Upper GI Endoscopy under some MACs). Medical necessity documentation must establish:

  • Documented dysphagia or obstruction symptoms
  • Identified esophageal stricture, stenosis, or narrowing on prior or current endoscopy
  • Clinical indication for mechanical dilation (benign vs. malignant)
  • History of prior dilation sessions if repeat procedure

• Frequency Limitations: Some MACs impose frequency edits on esophageal dilation procedures. Verify your MAC’s policy for number of sessions allowed per year without prior authorization (varies by payer and indication; malignant strictures may have less restriction than benign).

• Place of Service (POS): Commonly billed under:

  • POS 22 — Hospital Outpatient / HOPD
  • POS 24 — Ambulatory Surgical Center (ASC)
  • POS 21 — Inpatient Hospital (professional component)

• ASC Eligibility: 43248 is on the ASC covered procedures list. Confirm applicable ASC payment group under OPPS/ASC payment system.

• Multiple Dilations, Single Session: CPT instructs that dilation is reported once per session regardless of how many dilator passes are made. Never report multiple units of 43248 for multiple passes in the same operative session.

• Fluoroscopy: Whether fluoroscopy (e.g., 74360) can be separately billed alongside 43248 is MAC-specific. Some contractors bundle it; others allow separate reporting with documentation of a distinct, medically necessary radiologic component. Verify current MAC LCD guidance before billing 74360 with 43248.

• Same-Day Diagnostic EGD: If a diagnostic EGD was performed and immediately proceeded to guide wire dilation, report only 43248. The diagnostic component is inherent per NCCI edits and must not be separately billed.

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🔗 Related Codes & Cross-References

Code	Description	Relationship
43235	Diagnostic EGD	Base code; bundled into 43248
43239	EGD with injection, other than sclerotherapy	Intralesional steroid injection into stricture; NCCI edits apply same session
43245	EGD with dilation of gastric/duodenal stenosis	Dilation of pyloric/duodenal stenosis — distinct from esophageal dilation
43249	EGD with balloon dilation of esophagus, < 30 mm	TTS balloon technique — mutually exclusive with 43248 for same stricture, same session
43274	EGD with placement of endoscopic stent	Stent deployment — may follow dilation; bundling issues apply
43450	Dilation of esophagus, by unguided sound or bougie	Blind technique; no endoscope
43453	Dilation of esophagus over guide wire (non-endoscopic)	Wire-guided without flexible endoscopy
74360	Radiologic dilation of stricture (fluoroscopy-guided only)	Radiologic counterpart — non-endoscopic
K22.2	Esophageal obstruction	Primary indication — benign stricture
K20.00	Eosinophilic esophagitis without bleeding	Common indication in younger patients
K91.89	Postprocedural GI disorders	Anastomotic stricture — surgical history
C15.5	Malignant neoplasm of lower third of esophagus	Malignant stricture — HCC 10
E43	Severe protein-calorie malnutrition	Dysphagia-related nutritional complication — HCC 21
0D758ZZ	Dilation of Esophagus, Endoscopic, No Device	ICD-10-PCS inpatient equivalent — standard
0D738DZ	Dilation of Lower Esophagus, Endoscopic, Intraluminal Device	ICD-10-PCS — dilation + stent

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^{AMA CPT 2026 Professional Edition · CMS Physician Fee Schedule 2026 Final Rule · CMS NCCI Policy Manual v32 · ICD-10-CM Official Guidelines for Coding and Reporting FY2026 · ICD-10-PCS Official Guidelines FY2026 · CMS-HCC Risk Adjustment Model v28 · AHA Coding Clinic for ICD-10-CM/PCS · CMS MS-DRG Grouper & GROUPER Software FY2026 · UHDDS Principal Diagnosis Definition · Sharma P & Bhatt DL — Endoscopic Management of Esophageal Strictures, GIE 2023 · Hirano I et al., EoE Guidelines, Gastroenterology 2020}