Wiki Billing 43239 and 43248 together

[jessirussell2003]

We are now getting a frequent flow of denials, upheld denials after sending in NCCI Edits report, OP/Path notes and reconsideration letter for coding 43248 and 43239 together including the ins specific modifier. So I am asking for guidance as to how these should be billed. The ins companies are upholding denials d/t the 43248 (Dilation) and the 43239 (EGD w/BX) being both performed in the esophagus. It makes sense that yes they both are performed in the esophagus however you can't do a dilation with bx equipment and you can't do a bx with dilation equipment. So I totally feel this is fightable with the ins companies. I have previously added to my reconsideration letters about the equipment being different for each of those procedures and now just within the last month I am seeing the upheld denials based on they are both performed in the esophagus. I am looking for answers so we can fight these and get them paid. I thank you in advance. Jessica

 

[CBLENNIE]

43248 is a column 1 code to 43239, the column 2 code. 43248 is the more comprehensive procedure and the provider did not perform 2 different EGDs, they did 1 EGD and performed the dilation and biopsies during the same EGD session. Why do you believe that they are justified to bill and be reimbursed for 2 EGDs?

 

[xXxPARAGONxXx]

43248 is a column 1 code to 43239, the column 2 code. 43248 is the more comprehensive procedure and the provider did not perform 2 different EGDs, they did 1 EGD and performed the dilation and biopsies during the same EGD session. Why do you believe that they are justified to bill and be reimbursed for 2 EGDs?

Neither code pays for all the services that were performed, hence the reason both codes are being billed on the claim. Why should a provider not be paid for all the work they performed?

Also, the payer would not be paying at 100% for each CPT code. The column 2 code with modifier -59 is paid at 50%.

All in all, that seems absolutely reasonable.

Also, as an example, a provider can perform a colonoscopy and remove one polyp via hot biopsy forceps (45384) and another polyp via snare (45385) and then claim two codes for the same colonoscopy. The polyps can even be in the same segment of bowel (e.g., descending colon), just like the dilation and biopsy were in the same anatomical part (esophagus).

What's the difference? I wonder how the patient and the payer would feel if the provider asked the patient to return for a second EGD (to be paid at 100%) to provide the additional service since the payer only pays for one service per procedure? It would be unethical.

 

[jessirussell2003]

Neither code pays for all the services that were performed, hence the reason both codes are being billed on the claim. Why should a provider not be paid for all the work they performed?

Also, the payer would not be paying at 100% for each CPT code. The column 2 code with modifier -59 is paid at 50%.

All in all, that seems absolutely reasonable.

Also, as an example, a provider can perform a colonoscopy and remove one polyp via hot biopsy forceps (45384) and another polyp via snare (45385) and then claim two codes for the same colonoscopy. The polyps can even be in the same segment of bowel (e.g., descending colon), just like the dilation and biopsy were in the same anatomical part (esophagus).

What's the difference? I wonder how the patient and the payer would feel if the provider asked the patient to return for a second EGD (to be paid at 100%) to provide the additional service since the payer only pays for one service per procedure? It would be unethical.

I completely agree with your thoughts! That is the same interpretation we get from these as well. The ins companies used to pay and/or request records and I would send in the NCCI edits showing they can be billed together. But all of a sudden we are being hit with the denials based on same anatomical area, even though they are different instruments on the end of the scope to perform each procedure. Thanks for your feedback. Jessica