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- EVALUATION AND MANAGEMENT CPT code [99201-99499] - Full List
- Overall Medical billing process
- CPT Code 99201, 99202, 99203, 99204, 99205 - Which code to USE
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43239 Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple
43239 with biopsy, single or multiple
• Use code 43235 for a Diagnostic EGD procedure. Since this is classified as a “Separate Procedure” in the CPT book, it is not billable when a more extensive EGD procedure is performed.
• Two Upper Gastrointestinal Endoscopy procedures such as code 43239 for Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple and code 43245 for Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum, as appropriate; with dilation of gastric outlet for obstruction (e.g., balloon, guidewire, bougie) performed at the same setting would both be billable.
• If an EGD is done to collect a specimen for a CLO/H. Pylori test, since the test involves obtaining a tissue biopsy through the endoscope, the 43239 Biopsy code should be used. If the test is positive, the diagnosis code 041.86 for Helicobacter pylori (H. pylori) infection would be billed.
• If an EGD is performed with a biopsy, and then the physician removes the scope and performs an Esophageal Dilation by unguided sound, it should be billed using two CPT codes – CPT code 43239 for the scope with biopsy and code 43450 for the Esophageal Dilation would both be billed.
• Use CPT code 43248 if the patient has an EGD procedure with a flexible-tipped guidewire passed through the endoscope, the endoscope is withdrawn and the guidewire is left in place for dilators to be passed over the guidewire to dilate the Esophagus. If the guidewire is passed under fluoroscopic guidance for esophageal dilation, without the use of an endoscope, use CPT code 43453.
• The control of bleeding is included in biopsy (and most other) endoscopic procedures, and is not separately-billable. Control of bleeding can be obtained through means of injections, as well as cauterizations. Injections of Epinephrine through an endoscope are coded as 43255. This injection would be included in the ASC facility fee, and would not be reimbursed separately from the EGD procedure, unless the EGD case is completed and the patient is in the PACU and has a bleed, necessitating a return to the OR to treat the hemorrhage.
• For an EGD with a Polypectomy done by Cold Biopsy Forceps, use the 43258 Ablation code – not the 43239 Biopsy code.
Question and Answer Forum
Question: Do codes 43239 and 43255 require modifier 59? Which do I bill first, and to which code do I attach the modifier?
Answer: If the primary purpose of the endoscopy was control of bleeding, and a separate lesion/site was found, which required biopsy, then 43255 would be reported first; 43239 with 59 modifier would be reported for the second service, which would otherwise be bundled (i.e., biopsy of the bleeding site would not be separately reportable). If bleeding resulted from biopsy of a lesion and the treatment was for this purpose, the bleeding control would be considered part of the procedure (43239) and thus, 43255 would not be separately reported.
Unbundling occurs when multiple procedure codes are submitted for a group of procedures that are described by a single comprehensive code. An example of Unbundling would be fragmenting one service into component parts and coding each component as if it were a separate service. For example, the correct CPT comprehensive code to use for upper gastrointestinal endoscopy with biopsy of stomach is CPT code 43239. Separating the service into two component parts, using CPT code 43235 for upper gastrointestinal endoscopy and CPT code 43600 for biopsy of stomach is inappropriate (per CMS National Correct Coding Policy Manual).
Q: Can we code a 43239 with a 43249? I'm not sure if 43239 is included in 43249.
A: CPT guidelines permit the reporting of multiple endoscopy codes as appropriate. Codes 43239 and 43249 describe distinctly different procedures and should not be bundled by the payers. Both codes however include an upper GI endoscopy and payment adjustments should be expected for the duplicative portion. The issue becomes one of bundling - that is, is one code "bundled" in another by the payer? With the exception of Medicare, each carrier (Cigna, Aetna, Humana, etc.) has its own edits regarding bundling. There is no "national" bundling book for us to check in other than Medicare's Correct Coding Initiative (CCI). Under the CCI, these procedures are not bundled. I suggest that you report both services and monitor the EOB. If they are denied, I would appeal by referring to the distinct nature of the services and the CCI. It is helpful to have distinct ICD-9 codes (if appropriate) for the services to support the need for both of them on the same patient.
Upper GI Endoscopy with Biopsy CPT - 43239
Modifier 33: Preventive service; when the primary purpose of the service is the delivery of an evidence based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.
49585 Repair umbilical hernia, age 5 years or older; reducible
Hospital Outpatient Department
Peritoneal and Abdominal Procedures (CPT codes: 49491, 49492, 49495, 49496, 49500, 49501, 49505, 49507, 49520, 49521, 49525, 49540, 49550, 49553, 49555, 49557, 49560, 49561, 49565, 49566, 49570, 49572, 49580, 49582, 49585, 49587, 49590, 49600)
Ambulatory Surgery Center
49495, 49496, 495ØØ, 495Ø1, 495Ø5, 495Ø7, 4952Ø, 49521, 49525, 4954Ø, 4955Ø, 49553, 49555, 49557, 4956Ø, 49561, 49565, 49566, 4957Ø, 49572, 4958Ø, 49582, 49585, 49587, 4959Ø, , 496ØØ
Anthem Blue Cross and Blue Shield Central Region Clinical Claim Edit
Subject: Repair of reducible umbilical hernia with closure of gastrocolic fistula
Coverage is subject to the terms, conditions, and limitations of an individual member’s programs or products and the edit criteria listed below. Please compare the claim's date of adjudication to the range of the edit in question. Prior versions, if any, can be found below.
Description CODE : 49585
Anthem Central Region bundles CPT 49585 as incidental to CPT 43880. The performance of an abdominal procedure includes the reimbursement for hernia repair. The CMS National Correct Coding Manual states:
“If a hernia repair is performed at the site of an incision for an open or laparoscopic abdominal procedure, the hernia repair (e.g., CPT codes 49560-49566, 49652-49657) is not separately reportable. The hernia repair is separately reportable if it is performed at a site other than the incision and is medically reasonable and necessary. An incidental hernia repair is not medically reasonable and necessary and should not be reported separately.”
Therefore, if 49585 is reported in conjunction with 43880 – only 43880 is reimbursed.
15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy
15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (e.g. abdominoplasty) (includes umbilical transposition and fascial placation)
49560 Repair initial incisional or ventral hernia; reducible
49561 Repair initial incisional or ventral hernia; incarcerated or strangulated
49585 Repair umbilical hernia, age 5 or older; reducible
49587 Repair umbilical hernia, age 5 or older; incarcerated or strangulated
INDEPENDENT BILLING REVIEW FINAL DETERMINATION
Disputed Codes: Rev Codes 0250 x 4, 0271, 0272, 0370, 0710, CPT/HCPCS J7120, C1781, 49650, 49585, J0690, J1956, J2001 x 2, J2405, J2704, and J3010
ANALYSIS AND FINDING
Based on review of the case file the following is noted:
ISSUE IN DISPUTE: Provider seeking contractual reimbursement for Rev Codes 0250 x 4, 0271, 0272, 0370, 0710, CPT/HCPCS J7120, C1781, 49650, 49585, J0690, J1956, J2001 x 2, J2405, J2704, and J3010 for date of service 04/30/2015.
The Claims Administrator reimbursement rational: “Official Medical Fee Schedule,” and “contract indicated.”
Based on the aforementioned documentation and guidelines, additional reimbursement is indicated for Rev Codes 0250 x 4, 0271, 0272, 0370, 0710, CPT/HCPCS J7120, C1781, 49650, 49585, J0690, J1956, J2001 x 2, J2405, J2704, and J3010
BCBSIL Significant Edits - 49585
BCBSIL utilizes an automated code auditing system that is designed to review reported codes to ensure that the correct procedure codes are identified for reimbursement. Claims are audited to review for potential incorrect billing. The following codes represent those procedures that are reported in high volume and that are not separately payable when billed in conjunction with other procedures.
This service is incidental to primary procedure code. Payment is included in allowance for primary service.
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