CPT code 43245 is a medical billing code used for performing an endoscopic dilation of a stricture in the esophagus.
CPT code 43245 is used to describe the procedure of performing an endoscopic dilation of a stricture in the esophagus or stomach. This involves using an endoscope to insert a balloon or other device to widen a narrowed area, allowing for improved passage of food and liquids. This procedure is typically indicated for patients experiencing difficulty swallowing due to strictures caused by conditions such as gastroesophageal reflux disease (GERD) or other esophageal disorders.
For CPT code 43245 (EGD dilate stricture), the following modifiers may be applicable:
1. Modifier 22 (Increased Procedural Services): Used when the work required to perform the procedure is substantially greater than typically required. Documentation must support the substantial additional work and the reason for it.
2. Modifier 26 (Professional Component): Indicates that the service provided was the professional component only, such as the interpretation of a diagnostic test, and not the technical component.
3. Modifier 52 (Reduced Services): Applied when a service or procedure is partially reduced or eliminated at the physician's discretion. Documentation should explain why the service was reduced.
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): Indicates that a procedure or service was distinct or independent from other services performed on the same day. This modifier is used to identify procedures/services that are not normally reported together but are appropriate under the circumstances.
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): Indicates that 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 Following Initial Procedure for a Related Procedure During the Postoperative Period): Used when a related procedure is performed during the postoperative period of the initial procedure.
9. Modifier 79 (Unrelated Procedure or Service by the Same Physician During the Postoperative Period): Indicates that an unrelated procedure or service was performed by the same physician during the postoperative period.
10. Modifier 80 (Assistant Surgeon): Used when an assistant surgeon is required for the procedure.
11. Modifier 81 (Minimum Assistant Surgeon): Indicates that a minimum assistant surgeon was required for 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): Indicates that a physician assistant, nurse practitioner, or clinical nurse specialist provided services as an assistant at surgery.
14. Modifier GC (Service Performed in Part by a Resident Under the Direction of a Teaching Physician): Used when a resident performs a service under the supervision of a teaching physician.
15. Modifier QK (Medical Direction of Two, Three, or Four Concurrent Anesthesia Procedures Involving Qualified Individuals): Indicates that the physician provided medical direction for multiple anesthesia procedures.
These modifiers help provide additional information about the circumstances under which the procedure was performed, ensuring accurate billing and reimbursement.
The CPT code 43245, which involves a specific medical procedure, is subject to reimbursement by Medicare. To determine if this particular CPT code is reimbursed, healthcare providers should refer to the Medicare Physician Fee Schedule (MPFS). The MPFS provides detailed information on the payment rates for services covered under Medicare Part B. Additionally, it is essential to consult with the Medicare Administrative Contractor (MAC) for your specific region, as they are responsible for processing Medicare claims and can provide definitive guidance on the reimbursement status of CPT code 43245. The MAC can also offer insights into any local coverage determinations (LCDs) that may affect the reimbursement of this code.
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