CPT code 43242 is for an esophagogastroduodenoscopy (EGD) with fine needle biopsy or aspiration, used to examine and sample tissue from the upper GI tract.
CPT code 43242 is used to describe an esophagogastroduodenoscopy (EGD) procedure that involves the use of a fine needle for biopsy or aspiration. This code indicates that a healthcare provider is performing a minimally invasive procedure to examine the upper gastrointestinal tract, specifically the esophagus, stomach, and duodenum, while also obtaining tissue samples or fluid for diagnostic purposes.
For CPT code 43242, the following modifiers may be applicable:
1. Modifier 26 - Professional Component: This modifier is used when only the professional component of the service is being billed. It indicates that the provider is billing for the interpretation of the procedure, not the technical component.
2. Modifier 52 - Reduced Services: This modifier is used when the service provided is less extensive than described in the CPT code. It indicates that the procedure was partially reduced or eliminated at the physician's discretion.
3. Modifier 59 - Distinct Procedural Service: This modifier is used to indicate that a procedure or service was distinct or independent from other services performed on the same day. It is used to avoid bundling issues and to show that the procedures were separate and necessary.
4. Modifier 76 - Repeat Procedure by Same Physician: This modifier is used when the same procedure is repeated by the same physician. It indicates that the procedure was necessary to be performed more than once on the same day.
5. Modifier 77 - Repeat Procedure by Another Physician: This modifier is used when the same procedure is repeated by a different physician. It indicates that the procedure was necessary to be performed more than once on the same day by another provider.
6. Modifier 78 - Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period: This modifier is used when a patient requires a return to the operating room for a related procedure during the postoperative period.
7. Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period: This modifier is used when an unrelated procedure is performed by the same physician during the postoperative period of the initial procedure.
8. Modifier 80 - Assistant Surgeon: This modifier is used when an assistant surgeon is required during the procedure. It indicates that another surgeon assisted in the procedure.
9. Modifier 81 - Minimum Assistant Surgeon: This modifier is used when a minimum assistant surgeon is required during the procedure. It indicates that the assistance was minimal but necessary.
10. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available): This modifier is used when an assistant surgeon is required because a qualified resident surgeon was not available.
11. Modifier AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery: This modifier is used when a physician assistant, nurse practitioner, or clinical nurse specialist assists in the surgery.
These modifiers help provide additional information about the circumstances under which the procedure was performed, ensuring accurate billing and reimbursement.
CPT code 43242 is reimbursed by Medicare. This code is listed on the Medicare Physician Fee Schedule (MPFS) and is eligible for payment. However, coverage and reimbursement may vary depending on the specific Medicare Administrative Contractor (MAC) in your region. Healthcare providers should consult their local MAC for specific coverage guidelines and documentation requirements to ensure proper reimbursement for this procedure.
Discover the power of MD Clarity's RevFind software to ensure you're getting paid what you deserve. With RevFind, you can effortlessly read your contracts and detect underpayments down to the CPT code level, including specific codes like 43242. Don't let underpayments slip through the cracks—schedule a demo today and see how RevFind can optimize your revenue cycle management.
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
