Full Case: Preoperative diagnosis: Recurrent dysphagia. Postoperative diagnosis: Hiatal hernia with
obstruction. Procedure: EGD with dilation. Consent: PAR conference; informed consent signed;
premedication given. Position/monitoring:
left lateral decubitus; monitored with BP cuff and pulse oximeter throughout. Topical: Hurricaine spray to
posterior pharynx. Scope passage: flexible endoscope passed under direct visualization through
cricopharyngeus into esophagus; advanced with identification of EG junction into stomach; rugal folds
visualized; advanced to antrum/pylorus; pylorus cannulated; duodenal bulb and second portion visualized;
retroflexed views of cardia/fundus/lesser curvature. Dilation technique: guidewire placed in antrum; scope
removed; wire positioned by markings; #14 French dilator passed into stomach area; esophageal dilation
performed over guidewire. Findings: tortuous/shortened esophagus; large sliding hiatal hernia; EG junction
approximately 30 cm; stomach abnormal with very large sliding hiatal hernia; duodenum normal.
What CPT(R) coding is reported?