CPT code 43243 is a medical billing code used for an EGD procedure involving injection therapy for varices.
CPT code 43243 is used to describe the procedure of injecting varices during an esophagogastroduodenoscopy (EGD). This code specifically refers to the therapeutic intervention aimed at treating enlarged veins (varices) in the esophagus or stomach, which can be a serious condition often associated with liver disease. The injection helps to reduce the risk of bleeding by sclerosing the varices, thereby managing the patient's condition effectively.
For CPT code 43243 (Egd injection varices), the following modifiers may be applicable:
1. Modifier 22 - Increased Procedural Services
- Use this modifier if the procedure required significantly more work than typically required. This could be due to complications or other factors that increased the complexity of the procedure.
2. Modifier 26 - Professional Component
- This modifier is used when only the professional component of the service is being billed, typically in cases where the provider is only responsible for the interpretation of the procedure.
3. Modifier 52 - Reduced Services
- Apply this modifier if the procedure was partially reduced or eliminated at the physician's discretion.
4. Modifier 53 - Discontinued Procedure
- Use 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
- This modifier is 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
- Apply this modifier if the same procedure was repeated by the same provider on the same day.
7. Modifier 77 - Repeat Procedure by Another Physician or Other Qualified Health Care Professional
- Use this modifier if the same procedure was repeated by a different provider on the same day.
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
- This modifier is 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
- Apply this modifier if an unrelated procedure is performed by the same provider during the postoperative period of the initial procedure.
10. Modifier 80 - Assistant Surgeon
- Use this modifier if an assistant surgeon was required for the procedure.
11. Modifier 81 - Minimum Assistant Surgeon
- This modifier is used when a minimum assistant surgeon was required for the procedure.
12. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available)
- Apply this modifier if an assistant surgeon was required because a qualified resident surgeon was not available.
13. Modifier AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery
- Use this modifier when a physician assistant, nurse practitioner, or clinical nurse specialist assists in the surgery.
Each of these modifiers serves a specific purpose and should be used appropriately to ensure accurate billing and reimbursement.
The CPT code 43243 is reimbursed by Medicare, but the reimbursement is subject to specific conditions and guidelines outlined in the Medicare Physician Fee Schedule (MPFS).
The MPFS provides a comprehensive list of services covered by Medicare, including the associated reimbursement rates. Additionally, Medicare Administrative Contractors (MACs) play a crucial role in determining the local coverage and payment policies for this CPT code.
Providers should consult the MPFS and their respective MAC for detailed information on reimbursement rates and any additional requirements or limitations that may apply to CPT code 43243.
Discover how MD Clarity's RevFind software can meticulously read your contracts and detect underpayments down to the CPT code level and by individual payer. Ensure you're receiving accurate reimbursements for procedures like CPT code 43243. Schedule a demo today to 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
