CPT code 43130 is a medical billing code used for the removal of an esophageal pouch during surgical procedures.
CPT code 43130 is the procedure for the surgical removal of an esophageal pouch, which is an abnormal outpouching or dilation of the esophagus. This procedure is typically performed to address complications such as obstruction, inflammation, or cancer associated with the esophageal pouch.
For CPT code 43130, "Removal of esophagus pouch," the following modifiers may be applicable:
1. Modifier 22 - Increased Procedural Services: Use this modifier if the procedure required significantly greater effort or complexity than typically required.
2. Modifier 51 - Multiple Procedures: Apply this modifier if multiple procedures were performed during the same surgical session.
3. Modifier 52 - Reduced Services: Use this modifier if the procedure was partially reduced or eliminated at the physician's discretion.
4. Modifier 53 - Discontinued Procedure: Apply this modifier if the procedure was started but discontinued due to extenuating circumstances or those that threaten the well-being of the patient.
5. Modifier 59 - Distinct Procedural Service: Use this modifier to indicate that the procedure was distinct or independent from other services performed on the same day.
6. Modifier 62 - Two Surgeons: Apply this modifier if two surgeons were required to perform the procedure together, each acting as a primary surgeon.
7. Modifier 66 - Surgical Team: Use this modifier if the procedure required the services of a surgical team.
8. Modifier 76 - Repeat Procedure by Same Physician: Apply this modifier if the same physician performed the procedure more than once on the same day.
9. Modifier 77 - Repeat Procedure by Another Physician: Use this modifier if a different physician performed the procedure more than once on the same day.
10. Modifier 78 - Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period: Apply this modifier if the patient had to return to the operating room for a related procedure during the postoperative period.
11. Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period: Use this modifier if the procedure was unrelated to the original procedure and was performed during the postoperative period.
12. Modifier 80 - Assistant Surgeon: Apply this modifier if an assistant surgeon was necessary for the procedure.
13. Modifier 81 - Minimum Assistant Surgeon: Use this modifier if a minimum assistant surgeon was required for the procedure.
14. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available): Apply this modifier if an assistant surgeon was necessary due to the unavailability of a qualified resident surgeon.
15. Modifier AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery: Use this modifier if a non-physician practitioner assisted in the surgery.
These modifiers help provide additional context and detail about the circumstances under which the procedure was performed, ensuring accurate billing and reimbursement.
The CPT code 43130 is reimbursed by Medicare, but the reimbursement specifics can vary based on several factors. To determine if CPT code 43130 is covered and the reimbursement rate, healthcare providers should refer to the Medicare Physician Fee Schedule (MPFS). The MPFS provides detailed information on the payment rates for services covered by Medicare.
Additionally, it is essential to consult with your local Medicare Administrative Contractor (MAC). MACs are responsible for processing Medicare claims and can provide region-specific information regarding coverage and reimbursement for CPT code 43130. They can also offer guidance on any additional documentation or criteria that may be required for successful reimbursement.
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