CPT code 43257 is a medical billing code for an endoscopy procedure with thermal treatment for gastroesophageal reflux disease (GERD).
CPT code 43257 is for an esophagogastroduodenoscopy (EGD) procedure that includes thermal treatment for gastroesophageal reflux disease (GERD). This code indicates that the physician performed an endoscopic examination of the esophagus, stomach, and duodenum, along with a specific thermal intervention aimed at addressing the symptoms or complications associated with GERD.
For CPT code 43257 (Egd w/thrml txmnt gerd), 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 increased intensity, time, technical difficulty, or physical and mental effort.
2. Modifier 26 - Professional Component: Use this modifier if only the professional component of the service was provided. This is typically used when the procedure involves both a professional and technical component.
3. Modifier 52 - Reduced Services: Use 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: Use this modifier to indicate that the procedure was distinct or independent from other services performed on the same day. This is often used to avoid bundling issues.
6. Modifier 76 - Repeat Procedure by Same Physician: Use this modifier if the same procedure was repeated by the same physician on the same day.
7. Modifier 77 - Repeat Procedure by Another Physician: Use this modifier if the same procedure was repeated by a different physician on the same day.
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: Use this modifier if the patient had to return to the operating room for a related procedure during the postoperative period.
9. Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period: Use this modifier if the procedure was unrelated to the original procedure and was performed during the postoperative period.
10. Modifier 80 - Assistant Surgeon: Use this modifier if an assistant surgeon was required during the procedure.
11. Modifier 81 - Minimum Assistant Surgeon: Use this modifier if a minimum assistant surgeon was required during the procedure.
12. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available): Use 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 if a non-physician provider assisted in the surgery.
These modifiers help provide additional information about the circumstances under which the procedure was performed, ensuring accurate billing and reimbursement.
The CPT code 43257, which refers to a specific medical procedure, is reimbursed by Medicare under certain conditions. To determine if this code is reimbursed, healthcare providers should consult the Medicare Physician Fee Schedule (MPFS), which outlines the payment rates for services covered by Medicare.
Additionally, it is essential to check with the relevant Medicare Administrative Contractor (MAC) for your region, as they may have specific guidelines or requirements for reimbursement. The MACs are responsible for processing Medicare claims and can provide detailed information on whether CPT code 43257 is covered and any documentation or criteria that must be met for 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 43257, and by individual payer. Schedule a demo today to see how RevFind can ensure you're receiving the full reimbursement you deserve.
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