CPT code 43254 is for an endoscopic mucosal resection of the esophagus, a procedure to remove abnormal tissue.
CPT code 43254 is used to describe an endoscopic procedure known as an esophagogastroduodenoscopy (EGD) with mucosal resection. This procedure involves the removal of a specific area of abnormal tissue from the lining of the esophagus, stomach, or duodenum using an endoscope. It is typically performed to treat conditions such as early-stage cancer or precancerous lesions, allowing for both diagnosis and therapeutic intervention in a minimally invasive manner.
For CPT code 43254, which pertains to EGD endoscopic mucosal resection, 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. This could be due to increased complexity or difficulty of the procedure.
2. Modifier 26 (Professional Component): Used when only the professional component of the service is being billed, typically applicable when the procedure involves both a technical and a professional component.
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 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 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): Used when an unrelated procedure or service is 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): Used when a minimum assistant surgeon is 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): 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.
Determining if CPT code 43254 is reimbursed by Medicare involves consulting 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. Each MAC, which administers Medicare benefits in specific regions, may have additional guidelines or local coverage determinations (LCDs) that impact reimbursement.
To verify if CPT code 43254 is reimbursed, you should:
1. Check the MPFS: Access the MPFS database to see if CPT code 43254 is listed and review the associated reimbursement rates.
2. Consult Your MAC: Review any LCDs or other guidance documents issued by your regional MAC to ensure there are no specific restrictions or additional requirements for reimbursement.
By following these steps, you can confirm whether CPT code 43254 is reimbursed by Medicare and understand any regional variations that may apply.
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 43254. Schedule a demo today to see how RevFind can help you ensure accurate reimbursements from every payer.
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