Wiki 43244 & 43243 bundling??

[MedCoder0911]

Hello everyone,

I have a denial from an insurance company for code 43243. (They paid for 43244). Provider both banded and injected esophageal varices during this procedure. I do not see any CCI edits for these 2 codes so I used a 51 modifier. They are denying saying that these 2 codes are bundled and want the modifier changed from 51 to 59. I do not agree. Has anyone out there run into this situation? Any suggestions would be greatly appreciated.

Thank you!

 

[cwpierce]

CHAP6-CPTcodes40000-49999_final10312012.doc
Revision Date: 1/1/2013
CHAPTER VI
SURGERY: DIGESTIVE SYSTEM
CPT CODES 40000 - 49999
FOR
NATIONAL CORRECT CODING INITIATIVE POLICY MANUAL
FOR MEDICARE SERVICES

2. If multiple endoscopic services are performed, the most comprehensive code describing the service(s) rendered should be reported. If multiple services are performed and not adequately described by a single HCPCS/CPT code, more than one code may be reported. The multiple procedure modifier 51 should be appended to the secondary HCPCS/CPT code. Only medically necessary services may be reported. Incidental examination of other areas should not be reported separately.

Revision Date (Medicare): 1/1/2013
VI-5

It would appear that Insurance views 43243 as inclusive to 43244 thus the denial while NCCI Edits shows that both codes are seperately reportable and substantiated by the above guidelines. I would probably appeal the claim stating the above NCCI Edits guidelines for support of your appeal.

Hope this is helpful.

 

[bridgettemartin]

I think the "same site" rule would apply in this scenario. Similar to a biopsy and snare of the same polyp, you would only bill for the more extensive procedure. The Dr. used two methods to treat the same varices.