Gastroenterology Coding Alert

Question: How do we get a claim for 43239 through when filed along with 43248? We have tried using modifiers 51 and 59 but to no avail.  Do you have a suggestion to get these claims paid?

Indiana Subscriber

Answer: EGD coding can become a little complex sometimes.  Some payers may not pay for both the codes because the codes belong to the same family of EGD codes. The guidelines will differ from payers to payers. While some may require modifiers; others may not. The best way is get well versed in payer guidelines for multiple EGD claims.  It may help to attach modifier 59 (Distinct procedure or service) to 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple), but in Indiana, many commercial payers may want you to attach both the modifiers— modifiers 59 and modifier 51 (Multiple procedures) for many commercial payers.

Also, the clinical presentation of the case will define the reimbursement pattern. CPT^® code 43248 (Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire) is restricted to passage of dilators in the esophagus. CPT^® code 43239 is for EGD with biopsy from the esophagus, stomach, or duodenum. If the biopsy has been taken from the esophagus, then the services will get bundled. If the biopsy has been taken from the stomach or duodenum, then both codes can be paid since the stomach and duodenum is a separate anatomical location from the esophagus.