Gastroenterology Coding Alert

Question: What is the rule of thumb when a physician performs 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple) and 43249 (... with balloon dilation of esophagus [less than 30 mm diameter]) on a patient at the same session?

Florida Subscriber

Answer: First, you need to glance in your latest addition of the Correct Coding Initiative (CCI). You will find that these two codes are not bundled together. Therefore, you can report these two procedures separately following Medicare's multiple-endoscopy rule.

You can report both codes if the physician performed the biopsy at a separate site from the area dilated. When submitting a claim to Medicare or to a private carrier that follows Medicare rules, you should report 43249 first because it has the higher relative value units (RVU). Reimbursement for this procedure should be 100 percent of the standard fee. Use 43239 with modifier -59 (Distinct procedural service) attached to report the dilation. Reimbursement will be the difference between the biopsy code and the base code, 43235.