CPT code 43204 is a medical billing code for an esophagogastroduodenoscopy with sclerosis injection.
CPT code 43204 is for an esophagogastroduodenoscopy (EGD) procedure that includes the injection of a sclerosing agent. This procedure involves the use of a flexible scope to examine the esophagus, stomach, and the first part of the small intestine, while also administering a sclerotherapy treatment to manage conditions such as variceal bleeding or other abnormalities in the esophagus.
For CPT code 43204, which pertains to an esophagoscopy with sclerotherapy injection, the following modifiers may be applicable:
1. Modifier 22 - Increased Procedural Services: Used when the work required to provide a service is substantially greater than typically required.
2. Modifier 26 - Professional Component: Indicates that the service provided was the professional component only, such as the interpretation of a diagnostic test.
3. Modifier 52 - Reduced Services: Used when a service or procedure is partially reduced or eliminated at the physician's discretion.
4. Modifier 53 - Discontinued Procedure: Indicates that a 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: Used to indicate that a procedure or service was distinct or independent from other services performed on the same day.
6. Modifier 76 - Repeat Procedure by Same Physician: Used when a procedure or service is repeated by the same physician or other qualified healthcare professional subsequent to the original procedure or service.
7. Modifier 77 - Repeat Procedure by Another Physician: Used when a procedure or service is repeated by another physician or other qualified healthcare professional subsequent to the original procedure or service.
8. Modifier 78 - Unplanned Return to the Operating/Procedure Room by the Same Physician: Used for a related procedure during the postoperative period.
9. Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period: Indicates that the performance of a procedure or service during the postoperative period was unrelated to the original procedure.
10. Modifier 80 - Assistant Surgeon: Used when an assistant surgeon is required during the procedure.
11. Modifier 81 - Minimum Assistant Surgeon: Used when a minimum assistant surgeon is required during the procedure.
12. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available): Used when an assistant surgeon is required and a qualified resident surgeon is not available.
13. Modifier AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist services for assistant at surgery: Used when these non-physician practitioners assist in surgery.
These modifiers help provide additional information about the performed procedure, ensuring accurate billing and reimbursement.
When determining if CPT code 43204 is reimbursed by Medicare, it is essential to consult the Medicare Physician Fee Schedule (MPFS) and the guidelines provided by your regional Medicare Administrative Contractor (MAC). The MPFS is a comprehensive listing of the payment rates used by Medicare to reimburse physicians and other healthcare providers for services rendered.
For CPT code 43204, you would need to verify its inclusion and the corresponding reimbursement rate in the MPFS. Additionally, each MAC may have specific coverage policies and guidelines that could affect reimbursement. Therefore, it is advisable to check with your local MAC to confirm whether CPT code 43204 is reimbursed and to understand any specific requirements or limitations that may apply.
Discover the power of MD Clarity's RevFind software to ensure you're getting paid what you deserve. With the ability to read your contracts and detect underpayments down to the CPT code level, including specific codes like 43204, RevFind offers unparalleled accuracy by individual payer. Schedule a demo today to see how RevFind can optimize your revenue cycle and safeguard your practice's financial health.
Get paid in full by bringing clarity to your revenue cycle
Subscribe to the
Healthcare Clarified newsletter
Get the latest insights on RCM and healthcare policy in your inbox
