CPT code 43210 is a medical billing code for esophagogastroduodenoscopy with balloon dilation of the esophagus.
CPT code 43210 is used to describe an esophagogastroduodenoscopy (EGD) procedure that includes the performance of a therapeutic intervention known as esophageal fundoplasty. This procedure involves the examination of the esophagus, stomach, and the beginning of the small intestine, while also addressing issues related to the esophageal sphincter to help prevent reflux or other complications.
For CPT code 43210 (Egd esophagogastrc fndoplsty), 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 51 - Multiple Procedures: Used when multiple procedures are performed during the same session by the same provider.
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: Used when a procedure is 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 or Service by Same Physician or Other Qualified Health Care Professional: Used when a procedure or service is repeated by the same provider.
7. Modifier 77 - Repeat Procedure by Another Physician or Other Qualified Health Care Professional: Used when a procedure or service is repeated by a different provider.
8. Modifier 78 - Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period: Used when a patient returns to the operating room for a related procedure during the postoperative period.
9. Modifier 79 - Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period: Used when a procedure or service performed during the postoperative period is 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 providers assist in surgery.
Each of these modifiers serves a specific purpose and should be used appropriately to ensure accurate billing and reimbursement.
The CPT code 43210, which refers to a specific medical procedure, is subject to reimbursement by Medicare, but this depends on several factors. Medicare reimbursement for CPT code 43210 is determined by the Medicare Physician Fee Schedule (MPFS), which outlines the payment rates for services provided to Medicare beneficiaries.
To ascertain if CPT code 43210 is reimbursed, healthcare providers should consult the MPFS for the specific payment details and any applicable coverage guidelines. Additionally, Medicare Administrative Contractors (MACs) play a crucial role in this process. MACs are responsible for processing Medicare claims and can provide region-specific information regarding the reimbursement status of CPT code 43210. Providers should check with their respective MAC to confirm if this code is covered and to understand any local coverage determinations (LCDs) that may affect reimbursement.
Discover how MD Clarity's RevFind software can meticulously analyze your contracts and pinpoint underpayments down to the CPT code level, including specific codes like 43210. Schedule a demo today to see how RevFind can help you ensure accurate reimbursements from every payer.
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