CPT® Code 91040

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.