CPT code 43259 is a medical billing code for an endoscopic examination of the duodenum or jejunum using ultrasound.
CPT code 43259 is used to describe an esophagogastroduodenoscopy (EGD) procedure that includes an examination of the duodenum and jejunum. This code indicates that the healthcare provider performed a diagnostic endoscopic examination to visualize and assess the upper gastrointestinal tract, specifically focusing on the duodenum and jejunum, which are parts of the small intestine.
For CPT code 43259 (Egd us exam duodenum/jejunum), the following modifiers may be applicable:
1. Modifier 26 - Professional Component: Used when only the professional component of the service is being billed, typically by the physician who interprets the results.
2. Modifier 52 - Reduced Services: Applied when the service provided is less extensive than described in the CPT code.
3. 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.
4. Modifier 59 - Distinct Procedural Service: Indicates that a procedure or service was distinct or independent from other services performed on the same day.
5. Modifier 76 - Repeat Procedure by Same Physician: Used when the same physician repeats a procedure or service on the same day.
6. Modifier 77 - Repeat Procedure by Another Physician: Applied when a procedure or service is repeated by another physician on the same day.
7. 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 patient returns to the operating room for a related procedure during the postoperative period.
8. Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period: Indicates that a procedure performed during the postoperative period was unrelated to the original procedure.
9. Modifier 80 - Assistant Surgeon: Used when an assistant surgeon is required for the procedure.
10. Modifier 81 - Minimum Assistant Surgeon: Applied when a minimum assistant surgeon is required for the procedure.
11. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available): Used when an assistant surgeon is required because a qualified resident surgeon is not available.
12. Modifier AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery: Indicates that a non-physician provider assisted in the surgery.
Each of these modifiers serves a specific purpose and should be used appropriately to ensure accurate billing and reimbursement.
Determining whether CPT code 43259 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.
To ascertain if CPT code 43259 is reimbursed, you would first need to check the MPFS for the specific payment rate associated with this code. If the code is listed with an assigned payment rate, it indicates that Medicare does reimburse for this service. Additionally, it's crucial to review any Local Coverage Determinations (LCDs) or National Coverage Determinations (NCDs) issued by your MAC, as these documents provide detailed information on the coverage criteria and any specific conditions under which the service is reimbursed.
In summary, CPT code 43259 is reimbursed by Medicare if it appears on the MPFS with an assigned payment rate and meets the coverage criteria outlined by your MAC. Always ensure to verify the latest updates from both the MPFS and your MAC to stay compliant with Medicare's reimbursement policies.
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