Outpatient Facility Coding Alert

Question: My understanding has been that we do not include a modifier when billing for 43249 and 43239. However, I saw a bill where Medicare processed claims with modifiers 59 and 51 appended to 43239.  Do we use modifiers with these codes?

Michigan Subscriber

Answer: CCI edits do not show any bundling or modifier requirements for these codes so modifier 59 is not necessary. However, for the pro fee portion, you can append modifier 51 (Multiple procedures) to 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple) to indicate the multiple procedures as the RVU value of 43239 is less than 43249 (Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus [less than 30 mm diameter]). The total facility RVU for 43249 is 4.75 and is 4.25 for 43239.

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