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The esophageal balloon distension study, as described by CPT® Code 91040, is a diagnostic procedure aimed at investigating the underlying causes of recurrent unexplained chest pain and/or dysphagia, which is the medical term for difficulty swallowing. This study involves the insertion of a catheter equipped with a deflated balloon through the patient's nose and into the esophagus. Once positioned in the mid-esophagus, the balloon is gradually inflated with either air or water in controlled increments of 2 cc, with a maximum volume of up to 30 cc. The inflation is conducted in a manner that keeps the patient unaware of the exact volume being instilled, thereby minimizing any psychological influence on the symptoms experienced. Throughout the procedure, the patient is asked about any sensations of chest pain, and if the balloon distension elicits such symptoms, the physician records the volume of air or water used. The procedure may be repeated multiple times to provoke symptoms further, and the physician may also simulate the instillation of air or water without actually doing so to ascertain that the symptoms are indeed a result of the balloon distension. Upon completion of the study, the balloon is deflated, and the catheter is removed. The physician then interprets the findings and generates a written report detailing the results of the test.
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The esophageal balloon distension study is indicated for patients experiencing recurrent unexplained chest pain and/or dysphagia. This diagnostic procedure is particularly useful in cases where the etiology of these symptoms is not readily apparent, allowing for a more thorough investigation into potential underlying conditions affecting the esophagus.
The esophageal balloon distension study involves several key procedural steps that are critical for accurate diagnosis. Initially, a catheter with a deflated balloon is carefully inserted through the patient's nose and advanced into the esophagus. This step is crucial as it positions the balloon in the mid-esophagus, where it can effectively assess the esophageal response. Once the balloon is correctly placed, the physician begins to inflate it with air or water in small increments of 2 cc. This inflation continues until a total volume of up to 30 cc is reached. It is important that the inflation is performed discreetly, ensuring that the patient remains unaware of the exact volume being instilled, which helps to prevent any psychological influence on the symptoms being evaluated. Throughout the procedure, the physician actively queries the patient regarding any sensations of chest pain. If the inflation of the balloon reproduces these symptoms, the physician meticulously notes the volume of air or water that has been instilled at that point. The procedure may be repeated multiple times to further provoke symptoms and gather additional data. Additionally, the physician may simulate the instillation of air or water without actually doing so, which serves to confirm that the symptoms experienced by the patient are indeed a direct result of the balloon distension. After the completion of the test, the balloon is deflated, and the catheter is gently removed from the esophagus. Finally, the physician interprets the results of the study and compiles a written report that outlines the findings and any relevant observations.
Following the completion of the esophageal balloon distension study, the patient may experience some temporary discomfort, but this typically resolves quickly. The physician will interpret the results of the test and provide a detailed written report, which may include recommendations for further evaluation or treatment based on the findings. It is essential for the patient to follow any post-procedure instructions provided by the physician, which may include monitoring for any unusual symptoms or complications. The physician may also schedule a follow-up appointment to discuss the results and any necessary next steps in the management of the patient's condition.
| Short Descr | ESOPH BALLOON DISTENSION TST | Medium Descr | ESOPHGL BALO DISTENSION DX STD W/PROVOCATION | Long Descr | Esophageal balloon distension study, diagnostic, with provocation when performed | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | PC/TC Indicator (26, TC) | 1 - Diagnostic Tests for Radiology Services | Multiple Procedures (51) | 0 - No 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) | 0 - 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, Not Discounted when Multiple | Type of Service (TOS) | 1 - Medical Care | Berenson-Eggers TOS (BETOS) | P6C - Minor procedures - other (Medicare fee schedule) | MUE | 1 | CCS Clinical Classification | 97 - Other gastrointestinal diagnostic procedures |
| 26 | Professional component: certain procedures are a combination of a physician or other qualified health care professional component and a technical component. when the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number. | GC | This service has been performed in part by a resident under the direction of a teaching physician | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 74 | Discontinued out-patient hospital/ambulatory surgery center (asc) procedure after administration of anesthesia: due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (incision made, intubation started, scope inserted, etc). under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of modifier 74. note: the elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. for physician reporting of a discontinued procedure, see modifier 53. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | CR | Catastrophe/disaster related | FS | Split (or shared) evaluation and management visit | GW | Service not related to the hospice patient's terminal condition | TC | Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier tc; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2016-01-01 | Changed | Description Changed |
| 2005-01-01 | Added | First appearance in code book in 2005. |
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