CPT code 43258 is a medical billing code used for operative upper GI endoscopy procedures, helping healthcare providers document and bill services accurately.
CPT code 43258 is for an operative upper gastrointestinal (GI) endoscopy procedure. This code specifically refers to the performance of an endoscopic examination of the upper GI tract, which may include the esophagus, stomach, and duodenum, with the intent to perform therapeutic interventions such as biopsies, polypectomies, or other surgical procedures during the examination.
For CPT code 43258 (Operative upper GI endoscopy), 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.
2. Modifier 26 - Professional Component: Used when only the professional component of the service is being billed.
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 during the procedure.
11. Modifier 81 - Minimum Assistant Surgeon: Used when a minimum assistant surgeon is required during 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 these non-physician practitioners assist in surgery.
14. Modifier GC - This service has been performed in part by a resident under the direction of a teaching physician: Used in teaching settings where residents are involved in the care.
15. Modifier QK - Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals: Used when an anesthesiologist is directing multiple anesthesia procedures.
16. Modifier QS - Monitored anesthesia care service: Used to indicate monitored anesthesia care.
17. Modifier QX - CRNA service with medical direction by a physician: Used when a Certified Registered Nurse Anesthetist (CRNA) provides anesthesia services under the direction of a physician.
18. Modifier QY - Medical direction of one CRNA by an anesthesiologist: Used when an anesthesiologist directs a single CRNA.
19. Modifier QZ - CRNA service without medical direction by a physician: Used when a CRNA provides anesthesia services without the direction of a physician.
These modifiers help provide additional information about the circumstances under which the procedure was performed, ensuring accurate billing and reimbursement.
CPT code 43258 is reimbursed by Medicare. This code is listed on the Medicare Physician Fee Schedule (MPFS), which indicates that it is a covered service. However, reimbursement may vary depending on factors such as the specific Medicare Administrative Contractor (MAC) for your region, medical necessity documentation, and any applicable local coverage determinations (LCDs) or national coverage determinations (NCDs). It's important for healthcare providers to verify coverage and reimbursement details with their local MAC to ensure proper billing and payment for this procedure.
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