43450

🩺 CPT 43450 — Dilation Of Esophagus, By Unguided Sound Or Bougie, Single Or Multiple Passes

Quick Reference

wRVU: 1.25 | Global Period: 000 | Assistant Payable: No | Bilateral Indicator: 0 Rule: CPT 43450 carries a 000-day global, so the same-day pre-procedure work is bundled and a same-day E/M needs -25. The RVU file shows Assistant-at-Surgery indicator 1 (statutory restriction, assistant may not be paid), Co-Surgeon 0 and Team Surgery 0 (not permitted), and Bilateral 0 (the esophagus is a single midline organ, so -50, -RT and -LT do not apply). The non-facility practice expense (4.95) is far higher than the facility practice expense (0.79) because the code can be performed in an office with reusable bougies.¹

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📋 Clinical Description

CPT 43450 describes dilation of the esophagus using an unguided sound or bougie that is passed blindly, without endoscopic visualization and without a guide wire. The physician advances graduated dilators (Maloney-type bougies are the classic example) past the stricture, withdraws them, and repeats with larger French sizes until the target lumen is reached.^3,4 Because the descriptor reads “single or multiple passes,” the code is reported once per session regardless of how many dilators or passes are used.

The defining feature is the absence of a guide wire and of an endoscope. Dilation over a guide wire moves to 43453, and endoscopic dilation moves to codes such as 43249 (EGD with transendoscopic balloon dilation under 30 mm) or 43248 (EGD with guide-wire dilators), which already include the scope.^3,5 The PFS file lists 43450 at 1.25 wRVU versus 1.37 for 43453, and both are 000-day global procedures.¹

This procedure may be performed in the following clinical contexts:

• Peptic or reflux-related stricture — a patient with chronic reflux and progressive solid-food dysphagia undergoes serial bougie dilation, usually paired with K22.2 and K21.00.
• Post-radiation or post-surgical (anastomotic) stricture — narrowing after radiotherapy or an esophageal or hypopharyngeal anastomosis is stretched to restore lumen caliber.
• Caustic-ingestion sequela — after the acute injury has healed, dilation treats the residual stricture, and the injury history is captured with a corrosion code such as T28.6XXA when the encounter is still active treatment.
• Otolaryngology prosthesis work — hypopharyngeal or cervical esophageal bougie dilation before placing a tracheoesophageal voice prosthesis is reported with 43450 in published ENT coding guidance.

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🔬 Anatomical & Procedural Considerations

Variant	Mechanism	Key Notes
Blind bougie dilation (Maloney-type)	Tapered, weighted rubber dilators are passed through the mouth into the esophagus in ascending French sizes without a wire or scope.	Report 43450 once regardless of the number of passes. If a diagnostic EGD is also done, the EGD is coded separately.4
Unguided dilation with fluoroscopic monitoring	The same bougie technique is watched fluoroscopically to confirm position and effect.	43450 is still the dilation code because no wire is used. Radiological supervision and interpretation may be separately reportable with -26 when performed and documented; verify the PTP edit.10
Wire-guided dilators (Savary-type) — not 43450	A guide wire is placed and dilators are passed over it, with or without an endoscope.	Report 43453 or the endoscopic dilation family (43248, 43226) instead. Coders disagree on brand names, so let the operative note’s wire documentation decide.3

Clinical Pearl

The single most important documentation element is whether a guide wire was used, because that alone separates 43450 from 43453. “Multiple passes” is one unit, so expect a unit value of 1 and confirm it in the current practitioner MUE table.⁸ When dilation is performed through an endoscope, the dilation is coded with the EGD family rather than by adding 43450 to a diagnostic scope on top of a dilation code.

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✅ Procedure Includes

• Passage of one or more unguided sounds or bougies through the esophagus, including serial upsizing during the same session.
• Topical pharyngeal anesthesia and routine local anesthesia typically used for this procedure.
• Intra-service positioning, monitoring, and post-procedure observation immediately after the session.
• Pre-procedure evaluation that leads to the decision to dilate, because the decision is bundled in a 000-day global unless a separately identifiable E/M is documented.
• Same-day post-procedure care and routine instructions, since the 000-day global has no additional post-operative days.
• Selection of dilator size and stopping point based on resistance and tolerance, which is part of the physician work.

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❌ Excludes / Do Not Report Together

Code	Description	Relationship
43453	Dilation of esophagus, over guide wire	Mutually exclusive technique with 43450 for the same dilation. If a wire is used at any point to dilate, 43453 is the code. Reporting both for one dilation session duplicates the service.
43248	Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire	Includes the EGD and the wire-guided dilation, so 43450 is not added for the same dilation. Adding it would unbundle a service already described by the endoscopic code.
43249	Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter)	AAPC coding guidance describes 43450 as a column 2 code to 43249 with a non-overridable modifier indicator of 0. Verify the current NCCI PTP table before billing them together.5
43226	Esophagoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) over guide wire	Endoscopic wire-guided dilation already includes the dilation work. 43450 should not be layered on top of it for the same lumen.
74360	Intraluminal dilation of strictures and/or obstructions (e.g., esophagus), radiological supervision and interpretation	This is a separate radiology component, reported by the physician with -26 only when fluoroscopy is performed and interpreted. The base code is contractor-priced (status C), so payment attaches to the professional component.1,10

Bundling Alert

CPT 43450 is a 000-day global, so there is no post-operative period, and a repeat dilation on a later date is a new service that needs its own medical-necessity documentation rather than -58. Same-day return to the procedure room for a related complication is reported with -78, and a same-day repeat by the same physician is -76. NCCI edits and MUEs are applied to the same physician, beneficiary, and date of service, and units above the MUE draw scrutiny, so audit risk rises when multiple lines of 43450 appear without an unusual clinical reason.^7,8

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🌳 Code Tree — Surgery: Digestive System — Esophagus

CPT 43020-43499  Surgery: Digestive System — Esophagus
│
├── 43300-43425  Repair (Esophagus)
│   ├── 43420  Closure of esophagostomy or fistula; cervical approach  (Global: 090)
│   └── 43425  Closure of esophagostomy or fistula; transthoracic or transabdominal approach  (Global: 090)
│
├── 43450-43460  Manipulation (Esophagus)
│   ├── ▶▶ 43450 ◀◀  Dilation of esophagus, by unguided sound or bougie, single or multiple passes  ← YOU ARE HERE  (Global: 000)
│   ├── 43453  Dilation of esophagus, over guide wire  (Global: 000)
│   └── 43460  Esophagogastric tamponade, with balloon (Sengstaken type)  (Global: 000)
│
└── 43496-43499  Other Procedures (Esophagus)
    ├── 43496  Free jejunum transfer with microvascular anastomosis  (Global: 090)
    └── 43499  Unlisted procedure, esophagus  (Global: YYY)

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💰 RVU & Reimbursement Profile

Component	Value
Work RVU	1.25 (facility total 2.19; non-facility total 6.35). National unadjusted payment at the non-QPP conversion factor of 33.4009 is about $73.15facility/$212.10 non-facility, and at the QPP conversion factor of 33.5675 about $73.51/$213.15.1
Global Period	000 — same-day global with no pre- or post-operative days
Bilateral Indicator	0 — 150% bilateral adjustment does not apply; the esophagus is a single midline organ
Assistant Surgeon	1 — statutory payment restriction; assistant at surgery may not be paid
Co‑Surgeon	0 — co-surgeons not permitted
Team Surgery	0 — team surgeons not permitted
PC/TC Split	0 — physician service only; not divisible into professional and technical components, so -26 and -TC do not apply
Modifier -51 Exempt	Multiple Procedure indicator 2 — standard multiple-procedure payment rules apply; confirm exempt status in CPT Appendix E
Anesthesia	Billed by the anesthesia provider; the ASA crosswalk pairing was not confirmed from the project files, so verify it

Bilateral Billing Rules

Bilateral indicator 0 means the 150% bilateral payment rule does not apply, and the esophagus is a midline single structure. Do not append -50, -RT or -LT. Multiple passes are already contemplated by the descriptor, so they are never billed as separate units.

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🏷️ Modifier Reference

Modifier	Name	When to Apply
-25	Significant E/M	Append to the E/M when a significant, separately identifiable evaluation is documented beyond the usual pre-procedure work. Routine assessment before dilation is bundled into the 000-day global.
-51	Multiple Procedures	Apply to the lower-valued code when 43450 is reported with another procedure such as a diagnostic EGD. The file’s Multiple Procedure indicator of 2 means standard multiple-procedure reduction applies.
-59	Distinct Service	Use only when a PTP edit exists and the dilation is truly distinct from the other procedure, for example a different session or separate anatomic site. Do not use it to override an edit with modifier indicator 0.
-52	Reduced Services	Use when the dilation is partially completed or reduced by the physician’s election, and document the reason.
-53	Discontinued	Use when the procedure is stopped because of a threat to the patient’s well-being, such as intolerance or a complication, before the dilation is completed.
-76	Repeat Procedure, Same Physician	Use when the same physician repeats 43450 later on the same date of service for a documented clinical reason.
-78	Return to OR	Use for an unplanned return to the procedure or operating room for a related complication on the same day, such as bleeding or suspected perforation management.

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🩺 Common ICD‑10‑CM Pairings

Primary Diagnosis Group

ICD‑10	Description	HCC?	Notes
K22.2	Esophageal obstruction	❌ No	The most common indication; includes stricture and stenosis of the esophagus. The FY2026 code is billable, and it groups to MS-DRG 391/392 in v43.0.9
K22.0	Achalasia of cardia	❌ No	Bougie dilation is sometimes used for functional obstruction, though pneumatic balloon and myotomy techniques are more typical. Check the operative note for the dilator type.9
K22.4	Dyskinesia of esophagus	❌ No	Includes diffuse esophageal spasm. It has a Type 1 Excludes note for cardiospasm, which is K22.0.9
R13.14	Dysphagia, pharyngoesophageal phase	❌ No	Use when the physician documents the phase and no definitive cause has been established. Do not report it with K22.2 when the stricture explains the symptom.
R13.10	Dysphagia, unspecified	❌ No	A symptom code that is appropriate only when the phase and cause are undocumented. Query for specificity before final coding.

Secondary Group

ICD‑10	Description	HCC?	Notes
K21.00	Gastro-esophageal reflux disease with esophagitis, without bleeding	❌ No	Common underlying cause of a peptic stricture. Code it in addition to K22.2 when documented.
K21.9	Gastro-esophageal reflux disease without esophagitis	❌ No	Use when the reflux is documented without esophagitis.
K20.0	Eosinophilic esophagitis	❌ No	A recognized cause of strictures that need dilation. Add K22.2 when a stricture is documented as well.

Etiology / Complication

ICD‑10	Description	HCC?	Notes
K91.89	Other postprocedural complications and disorders of digestive system	❌ No	Can capture a postprocedural or anastomotic stricture; it carries a “use additional code, if applicable, to further specify disorder” note.9
T28.6XXA	Corrosion of esophagus, initial encounter	❌ No	A billable 7-character code. Assign the 7th character by encounter type, and add the external cause code.9
K22.70	Barrett’s esophagus without dysplasia	❌ No	A downstream complication of chronic reflux that often coexists with strictures.

Coding Specificity Reminder

Code to the highest specificity documented and do not report a symptom such as dysphagia when a definitive diagnosis such as a stricture explains it. Confirm each code is valid for the date of service, and never report a parent or header code. HCC flags shown here are all “No” but should be confirmed against the current CMS-HCC V28 mapping file.

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🏥 MS‑DRG Considerations

The professional-fee CPT 43450 does not determine MS-DRG assignment; facility grouping follows the principal diagnosis and any CC/MCC secondary diagnoses. For example, K22.2 groups to MDC 06, MS-DRG 391 (with MCC) and 392 (without MCC) in v43.0, and the ICD-10-PCS esophageal dilation codes are generally non-OR, so they should not change the DRG.^9,11 NCD/LCD: I found no NCD dedicated to CPT 43450. The NCDs cross-referenced by First Coast LCD L33583 are NCD 100.2 (Endoscopy) and NCD 100.3 (24-Hour Ambulatory Esophageal pH Monitoring), which address endoscopic and pH-monitoring services rather than unguided bougie dilation.⁶ LCD L33583 (First Coast Service Options — FL, PR, VI) supports therapeutic EGD dilation of strictures after a definitive diagnosis and notes that surveillance of healed benign strictures is not usually indicated, but it belongs to a different MAC than Noridian JE/JF and is a reference only. PFS Lookup comparison: the RVU file shows status A with payable non-facility and facility values, and it does not embed coverage rules, so any medical-necessity limit comes from a local article. I did not locate a Noridian LCD or billing article listing 43450, and MCD code lists are license-gated, so confirm in the MCD search with your MAC selected.^1,2

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🔧 ICD‑10‑PCS Equivalents

PCS Code	Full Description	Modality
0D757ZZ	Dilation of Esophagus, Via Natural or Artificial Opening. This is the closest match for unguided bougie dilation without a device.	Blind bougie, no device
0D757DZ	Dilation of Esophagus with Intraluminal Device, Via Natural or Artificial Opening. Used when a device such as a stent is left in place.	Natural opening, intraluminal device
0D758ZZ	Dilation of Esophagus, Via Natural or Artificial Opening Endoscopic. Used when the dilation is done through an endoscope.	Endoscopic
0D758DZ	Dilation of Esophagus with Intraluminal Device, Via Natural or Artificial Opening Endoscopic. Used for endoscopic dilation with a device left in place.	Endoscopic, intraluminal device

PCS Character Analysis (0D757ZZ)

Position	Character	Value	Definition
1	Section	0	Medical and Surgical, the section that contains root-operation-based procedures.
2	Body System	D	Gastrointestinal System, which includes the esophagus.
3	Root Operation	7	Dilation — expanding an orifice or the lumen of a tubular body part.
4	Body Part	5	Esophagus. Upper, middle, and lower esophagus have their own values (1, 2, 3) when documented.
5	Approach	7	Via Natural or Artificial Opening, meaning no incision and no endoscope.
6	Device	Z	No Device, because nothing is left in the lumen.
7	Qualifier	Z	No Qualifier.

Root Operation Comparison

• Dilation (7) versus Insertion (H): if a stent or other device is left behind, the device is coded through Insertion or through the device value in the dilation table, depending on the documentation, and CPT would move to a stent code such as 43212.
• Dilation (7) versus Inspection (J): a diagnostic look without dilation is Inspection, which pairs with diagnostic esophagoscopy or EGD rather than 43450.
• Verify the approach and device characters in your encoder for the date of service.

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📝 Coding Examples

Example 1

Clinical Scenario: A 71-year-old inpatient with progressive solid-food dysphagia has a known peptic stricture. The gastroenterologist passes Maloney bougie dilators at the bedside in ascending sizes to 54 French without a guide wire or scope. The patient tolerates it and is monitored afterward.

Field	Code	Rationale
CPT	43450	Unguided bougie dilation with multiple passes is one unit.
PDx	K22.2	The stricture is the definitive diagnosis and explains the dysphagia, so the symptom is not coded separately.
SDx	K21.00	Documented reflux esophagitis as the underlying cause.

Note

Confirm the note documents no guide wire, or the code changes to 43453. Because the global is 000, no separate post-operative visit is reported.

Example 2

Clinical Scenario: A patient with dysphagia undergoes a flexible diagnostic EGD. During the same session, the physician passes unguided Maloney bougies to dilate a distal esophageal stricture found on the exam. No guide wire or balloon is used.

Field	Code	Rationale
CPT 1	43235	Diagnostic EGD with brushings or washings when performed.
CPT 2	43450 -51	Unguided bougie dilation is separately reportable per ASGE guidance; verify the PTP table and apply multiple-procedure rules.
PDx	K22.2	The stricture found and dilated.

Warning

If the dilation is performed over a guide wire through the scope, report 43248 alone rather than 43235 plus 43450, and if a balloon under 30 mm is used, report 43249.⁴

Example 3

Clinical Scenario: A patient admitted with a corrosive stricture undergoes bougie dilation on hospital day 2 and again on hospital day 4 as part of a planned serial dilation program. Each session is documented separately with the dilator sizes used.

Field	Code	Rationale
CPT	43450	Reported for each date of service that is documented and medically necessary.
PDx	T28.6XXA	Initial-encounter corrosion code while the patient is receiving active treatment.

Global period reminder

The 000-day global ends on the date of the procedure, so a planned repeat on a later date needs no -58 and stands on its own documentation. A same-day repeat is -76.

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⚠️ Common Coding Pitfalls

• Pitfall 1: Reporting 43450 when a guide wire was used. The wire is the only difference between 43450 and 43453, so read the operative note carefully.
• Pitfall 2: Adding 43450 to an EGD dilation code such as 43248 or 43249. The endoscopic code already describes the dilation, and published guidance treats 43450 as a bundled column 2 code with a non-overridable indicator.
• Pitfall 3: Billing multiple units for multiple passes. The descriptor already says “single or multiple passes,” so one unit is reported per session, and the practitioner MUE should be checked.
• Pitfall 4: Appending -50, -RT or -LT. The esophagus is a single midline organ, and bilateral indicator 0 means these modifiers do not apply.
• Pitfall 5: Billing the assistant or a co-surgeon. The file shows assistant at surgery as not payable and co-surgeon and team surgery as not permitted, so those claims will deny.
• Pitfall 6: Forgetting -25 on a same-day E/M, or using -24 or -58 for a repeat session. The 000-day global has no post-operative days, so the later session simply stands as a new service.

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📎 Sources

1. Centers for Medicare & Medicaid Services. *CY 2026 Physician Fee Schedule Relative Value File (PPRRVU2026 January release, QPP and non-QPP).* CMS; released 12/29/2025. https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files 2. Centers for Medicare & Medicaid Services. *Physician Fee Schedule Look-Up Tool.* CMS; 2026. https://www.cms.gov/medicare/physician-fee-schedule/search 3. AAPC. *Esophageal dilation (43450 vs 43453) — Medical Billing and Coding Forum.* AAPC; 2010. https://www.aapc.com/discuss/threads/esophogeal-dilation.28009/ 4. American Society for Gastrointestinal Endoscopy. *Practical Solutions: July Answers to Your Coding Questions.* ASGE. https://www.asge.org/home/resources/publications/practical-solutions/practical-solutions-july-answers-to-your-coding-questions 5. AAPC. *You Be the Coder: Remember Multiple-Endoscopy Rule.* My General Surgery Coding Alert; 2019. https://www.aapc.com/codes/coding-newsletters/my-general-surgery-coding-alert/you-be-the-coder-remember-multiple-endoscopy-rule-161028-article 6. First Coast Service Options, Inc. *LCD L33583 — Diagnostic and Therapeutic Esophagogastroduodenoscopy.* CMS Medicare Coverage Database; revision effective 10/01/2019. https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33583 7. Centers for Medicare & Medicaid Services. *Medicare NCCI Policy Manual, Chapter VI (2026).* CMS; 2026. https://www.cms.gov/files/document/06-chapter6-ncci-medicare-policy-manual-2026-final.pdf 8. Centers for Medicare & Medicaid Services. *Medicare NCCI Medically Unlikely Edits (MUEs), Practitioner Services.* CMS; 2026. https://www.cms.gov/medicare/coding-billing/national-correct-coding-initiative-ncci-edits/medicare-ncci-medically-unlikely-edits-mues 9. icd10data.com. *2026 ICD-10-CM codes K22.2, K22.0, K22.4, K22 hierarchy, T28.6XXA, K91.89.* Effective 10/01/2025. https://www.icd10data.com/ICD10CM/Codes/K00-K95/K20-K31/K22-/K22.2 10. AAPC. *You Be the Coder: Detail Maloney Bougie Dilator.* My General Surgery Coding Alert; 2015. https://www.aapc.com/codes/coding-newsletters/my-general-surgery-coding-alert/you-be-the-coder-detail-maloney-bougie-dilator-147649-article 11. Centers for Medicare & Medicaid Services. *ICD-10-PCS Table 0D7 (Dilation, Gastrointestinal System), FY 2026.* CMS; 2025. https://www.cms.gov/medicare/coding-billing/icd-10-codes

_{Sources listed above correspond to superscript citations throughout this note. Verify all Medicare payment figures against your current CMS PFS Lookup tool and applicable MAC LCD prior to claim submission. Please use the latest AAPC/AHIMA Coding Books to verify each code within this note.}