0D7B8DZ
Dilation Ileum to No Qualifier with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | D Gastrointestinal System |
| Operation | 7 Dilation |
| Body Part | B Ileum |
| Approach | 8 Via Natural or Artificial Opening Endoscopic |
| Device | D Intraluminal Device |
| Qualifier | Z No Qualifier |
Operation Definition
Expanding an orifice or the lumen of a tubular body part
Procedure Overview
This family covers procedures that widen a narrowed opening or segment of the digestive tract, most commonly a stricture in the esophagus from acid reflux or scarring, a tight pyloric channel, or a narrowed anastomosis after prior bowel surgery. The narrowing is stretched open using an inflatable balloon or a series of graduated dilators, typically passed during an upper endoscopy or colonoscopy.
People need this procedure when a stricture is causing symptoms like difficulty swallowing, food getting stuck, vomiting, or abdominal pain from partial blockage. Dilation does not remove tissue; it stretches the existing structure to restore a more normal caliber, and the effect may be temporary, requiring repeat sessions over time.
Anatomy & Axis Detail
Ileum
The ileum, the final and longest segment of the small intestine terminating at the ileocecal valve, is a common site of stricture in Crohn disease, where chronic transmural inflammation produces fibrotic narrowing distinct from the acute inflammatory strictures seen elsewhere. Dilation of the ileum is frequently performed to relieve obstructive symptoms and delay or avoid resection, using balloon catheters passed via colonoscopy retrograde through the ileocecal valve or via device-assisted enteroscopy for more proximal disease. Because the terminal ileum absorbs vitamin B12 and bile salts, repeated instrumentation or subsequent resection in this region carries functional consequences worth noting in the record, and documentation should distinguish primary ileal strictures from those at a prior ileocolic anastomosis.
Approach: Via Natural or Artificial Opening Endoscopic
Via Natural or Artificial Opening Endoscopic describes instrumentation introduced through a natural orifice or a surgically created opening while using an endoscope for visualization, as in a routine colonoscopy performed through the anus. It differs from the plain Via Natural or Artificial Opening value by the added scope, and from Percutaneous Endoscopic by using an existing passage rather than a new skin puncture.
Device: Intraluminal Device
Intraluminal Device denotes a single device, such as a stent or occlusion device, positioned within the lumen of a tubular body part like a vessel, duct, or airway to maintain patency or occlude flow. It carries no drug coating or radioactivity, distinguishing it from the drug-eluting, radioactive, and bioactive intraluminal device values, and from Extraluminal Device, which sits outside rather than inside the lumen.
Coding & Documentation
Coders assign from this family when notes describe a balloon or bougie dilator advanced through a narrowed segment to stretch it, with the specific site - esophagus, pylorus, or a named anastomotic stricture - clearly stated. Documentation should note the device used, since balloon and bougie dilation may carry different device values, and whether the procedure was done via natural orifice endoscopy versus an open or percutaneous approach. A common error is failing to code dilation separately when it is performed as an incidental step during a colonoscopy that also included biopsy or polyp removal, since each distinct root operation performed should be captured. Another mistake is confusing dilation of a true stricture with simple passage of an endoscope through a tight but non-stenotic area, which would not qualify as a procedure on its own.