Wiki CPT 43281-59 BILLED WITH 43775

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tiffanie0812@yahoo.com

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I keep getting denials for CPT 43281-59 as bundled with 43775. Even after the medical records are reviewed by the payer. Does anyone know if CPT code 43281 can ever be paid when billed with CPT 43775? Also, if you can guide me to documentation stating they cannot be billed together even with a modifier that would be wonderful (if that is the case). Thank you!!
 
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The short answer is it depends on the circumstances and documentation. It is bundled. CCI edits allow a modifier 59 to be applied to the 43281. However, use of modifier 59 is indicative of a "distinct procedural service." From CMS, "documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual...."
 
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Would this support billing 43281 in addition to a bariatric procedure?
The paraesophageal hernia was addressed first. The paraesophageal fat pad and the associated hernia sac were removed with a harmonic scalpel anteriorly. Peritoneum along the angle his was first divided exposing the left crus fully. I could clearly appreciate is the posterior wall the stomach herniating into the mediastinum. At this time, the pars flaccida was divided with harmonic scalpel. Clear plane between the right crus in the posterior wall the stomach was developed. This area was completely scarred due to the passage of the laparoscopic adjustable gastric band in the past. The retroesophageal window was more difficult to create for this reason. The posterior hernia sac was excised at this time. Full mobilization of the esophagus was performed reducing the stomach out of the mediastinum. With the 36 French tube in place, the paraesophageal hernia was repaired using 2-0 Ethibond stitch in a figure-of-eight manner completing the posterior cruroplasty.
 
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