Wiki Dilations and Biopsies during EGD

[SamanthaLunde]

My physicians will very seldom require to use an alternate method of dilation when one doesn't produce the result they desire. For example, they will perform a 43248(guide wire) and a 43249(balloon) in the same session. Most recently, we billed those two codes along with a 43239(biopsy) and received a denial only for the biopsy. Both dilations were allowed and paid. Is anyone aware of a new CCI edit or otherwise restricting these code parings? If we were to bill only one dilation with the biopsy we would be paid substantially more then the payments received for both dilations which makes no sense. Thoughts appreciated.

 

[mkmgt001]

43239 and 43249

I have a related question. If an EGD with balloon dilation (ie. 43249) is performed on an esophageal stricture and biopies of the esophagus are taken to evaluate for eosinophilic esophagitis (EoE), would it be appropriate to report 43239-59 in addition to 43249? OR because both of these procedures were performed on the same anatomical site (ie. esophagus) and during the same patient encounter, should only 43249 be reported? CMS National Correct Coding Initiative (CCI) edits indicate that the reporting of 43239 with 43249 is a “Misuse of column two code with column one code”, but a modifier override IS allowed. I'm trying to determine when a modifier override is appropriate.

I appreciate any input.

 

[afalcon@dhcla.com]

I would use whatever technique completed the dilatation and use 43239-59 for the bx. I would hold the charge until you get the path back to make sure you have EOE or another dx to justify the bx.

1.) 43349 R13.14
2.) 43239-59 K20.0