43244

Esophagogastroduodenoscopy with band ligation of esophageal varices

Esophagogastroduodenoscopy (EGD) with band ligation, also known as Endoscopic Variceal Ligation (EVL), is a therapeutic endoscopic procedure used primarily to treat and prevent hemorrhage from esophageal varices. These varices are dilated submucosal veins in the lower esophagus, usually resulting from portal hypertension associated with liver cirrhosis. During the procedure, a flexible, fiberoptic endoscope is passed transorally into the esophagus, stomach, and duodenum. A specialized multi-band ligating device is attached to the distal tip of the endoscope. Once the physician identifies the target varices, the endoscope is positioned over the varix, and suction is applied to draw the vascular tissue into a small chamber or cap at the end of the scope. A small elastic band is then deployed around the base of the varix, effectively strangulating the vessel and obstructing blood flow. This process induces local thrombosis and subsequent tissue necrosis over the following days. As the necrotic tissue sloughs off, a shallow ulcer forms and eventually heals into a fibrous scar, which obliterates the varix and prevents future bleeding. The physician typically begins ligation at the gastroesophageal junction and moves proximally as needed. The procedure is performed under conscious sedation or general anesthesia, and the physician also conducts a full diagnostic sweep of the upper gastrointestinal tract to ensure no other pathologies are present. EVL is considered the gold standard for both the primary prophylaxis of bleeding in patients with large varices and the management of acute variceal hemorrhage.

Clinical Indications

  • Acute hemorrhage from esophageal varices
  • Primary prophylaxis for patients with medium to large esophageal varices and high risk of bleeding
  • Secondary prophylaxis to prevent recurrent bleeding in patients with a history of variceal hemorrhage
  • Screening and surveillance of varices in patients with known cirrhosis and portal hypertension
  • Treatment of esophageal varices that have failed sclerotherapy

Procedure Steps

  1. Administration of intravenous sedation or general anesthesia and monitoring of vital signs.
  2. Insertion of the flexible endoscope with a pre-loaded multi-band ligator device through the mouth.
  3. Advancement of the endoscope through the esophagus and into the stomach for a preliminary diagnostic survey.
  4. Identification and grading of esophageal varices based on size and presence of 'red wale' signs.
  5. Positioning the endoscope tip and the ligator cap directly against the most prominent or bleeding varix.
  6. Application of suction to pull the varix into the ligator cap.
  7. Deployment of a rubber band around the neck of the suctioned varix.
  8. Repetition of the suction and ligation process for other high-risk variceal columns.
  9. Verification of hemostasis and secure band placement.
  10. Withdrawal of the endoscope and post-procedural monitoring for complications like perforation or immediate re-bleeding.

Coding Guidelines

  • CPT 43244 includes the diagnostic portion of the EGD (43235); do not report 43235 separately.
  • If endoscopic sclerotherapy (43243) is performed on the same varix or during the same session, consult NCCI edits; typically, only one therapeutic code is reported per site.
  • If the procedure is performed for active bleeding control, 43244 is the specific code; do not additionally report 43255 for the same site.
  • Report 43244 once per session regardless of the number of bands applied.
  • For esophagoscopy with band ligation that does not reach the stomach or duodenum, see code 43204.
  • If the procedure is converted from a diagnostic EGD to a therapeutic ligation, only 43244 is reported.

Associated ICD-10 Codes