# CPT 43249 and 43239



## lamiller (Mar 2, 2021)

Can someone tell me why I am not getting paid for both 43249 and 43239-XS with Blue Cross Medicare Advantage plans?

43249 was billed with DX code K22.2 and 43239-XS was billed with K31.89 and R13.19.

I thought these were not bundled together.

Thanks in advance for any help


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## Annageesling85 (Apr 14, 2021)

Use modifier 59 with 43239


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## Orthocoderpgu (Apr 14, 2021)

These codes hit an edit. Where the the biopsy taken from? If the biopsy was taken from the esophagus, stomach or duodenum it would be bundled, right?


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## cfostercpc (May 5, 2021)

It could be because you have a dysphagia diagnosis code on your biopsy.  If your physician dilated the esophagus and took biopsies in that area then it would be bundled.  However, if he biopsied the stomach then it should be separately payable but you may need to send an appeal with medical records to get paid.


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## ashae17 (May 5, 2021)

There is an edit between these two codes. The XS modifier can be used to override the edit for procedures where separate lesions are involved. I think because CPT 43249 is not a procedure performed on a lesion, it may not fall under this category. 

NCCI edits:
"If the corresponding procedures are performed at the same patient encounter and in contiguous structures, NCCI PTP-associated modifiers should generally not be used." 

Here is the exception:
"Biopsy performed at the time of another more extensive procedure (e.g., excision, destruction, removal) is separately reportable under specific circumstances. If the biopsy is performed on a separate lesion, it is separately reportable. This situation may be reported with anatomic modifiers or modifier 59 or XS."

The treatment of _contiguous structures_ in the same organ or anatomic region does not generally constitute treatment of different anatomic sites. 

Basically, even if the biopsy was technically performed in a separate area during the EGD, it could still be considered inclusive, because these are all contiguous structures. This is just my guess and past experience however I'm not sure if there is a loophole to this.


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## lfoot56@yahoo.com (May 18, 2021)

I would used modifier 59 too.
Check you payment.  Is the payment for 43249 higher than usual.  Your payment for the second procedure could be wrapped all it one.


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