Wiki TIF Procedure

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bdye

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I have a general surgeon who is asking that we use a code, other than the 43499 which is what we have been advised to use. During the course of looking for another procedure, I have learned a lot. First, Medicare (Cahaba) will not pay for this procedure - stating insufficient evidence to compare this endoscpoic TIF to surgery. I think this is the reason that the physician is asking me to use 43280 with a modifier -52. It has always been my undertanding that modifier -52 is for when you are reporting reduced services WITHOUT DISTURBING THE THE IDENTIFICATION OF THE BASIC SERVICE. 43280 requires a surgical laproscopy. The TIF is INCISIONLESS. I have seen previous threads on this subject, going back to 2011 - I am hoping that there is more inofrmation out there now. Key word here - Hoping. Thanks for any and all input on this.:)
 
Tif

My surgeon is also doing the TIF procedure and the unlisted code 43499 is the appropriate code, at least until the AMA assigns a code. Unfortunately, at least in our area (Montana) the company didn't do a very good job of marketing and getting insurance companies on board before training physicians to do the procedure. Almost all of the insurance companies we are contracted with, including Medicare, consider the procedure investigational and do not cover it. Endogastric Solutions has a person that will do all of the predeterminations work for you and handles all of the appeals as well if that is who you are working with. To date, Medicaid and Allegiance (after 3rd level appeal) have approved the procedure. There was an article that Noridian (Medicare) published that specifically discusses the TIF being a non-covered procedure for 2013. Cigna, even after provider to provider discussion refuses to approve the procedure. Until more insurance companies update their out-dated policies, there really isn't much we as coders can do.
 
bdye

Thanks for the information. Cahaba (state of TN) has said that several significant trials will be finished in 2013 and that they will reconsider after the trials are published.
 
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