CPT code 43260 is a medical billing code for an endoscopic retrograde cholangiopancreatography procedure with specimen collection.
CPT code 43260 is for an Endoscopic Retrograde Cholangiopancreatography (ERCP) procedure that includes the collection of specimens. This code indicates that the healthcare provider performed a specialized endoscopic procedure to visualize and potentially treat issues in the bile ducts and pancreatic duct, while also obtaining tissue samples or fluid for further analysis.
For CPT code 43260 (ERCP with specimen collection), 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 complications or additional time and effort.
2. Modifier 26 - Professional Component: Indicates that the service provided was the professional component only, such as the interpretation of the procedure.
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: Indicates that 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: 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: Indicates an unplanned 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: Used when an unrelated procedure or service is performed by the same physician during the postoperative period.
10. Modifier 80 - Assistant Surgeon: Indicates that an assistant surgeon was required for the procedure.
11. Modifier 81 - Minimum Assistant Surgeon: Used when a minimum assistant surgeon was required for the procedure.
12. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available): Indicates that 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: 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 to indicate that a resident performed part of the service under the supervision of a teaching physician.
15. Modifier QX - CRNA service with medical direction by a physician: Used when a Certified Registered Nurse Anesthetist (CRNA) provides anesthesia services under the medical direction of a physician.
16. Modifier QY - Medical direction of one CRNA by an anesthesiologist: Indicates that an anesthesiologist is directing the anesthesia care of one CRNA.
17. Modifier QK - Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals: Used when an anesthesiologist is directing multiple anesthesia procedures concurrently.
These modifiers help provide additional information about the circumstances under which the procedure was performed, ensuring accurate billing and reimbursement.
Determining if CPT code 43260 is reimbursed by Medicare involves consulting the Medicare Physician Fee Schedule (MPFS) and the guidelines set forth by the Medicare Administrative Contractor (MAC) for your specific region. The MPFS provides a comprehensive list of services covered by Medicare, including the reimbursement rates for each CPT code.
To verify if CPT code 43260 is reimbursed, you would need to check the MPFS database. This can be done through the Centers for Medicare & Medicaid Services (CMS) website, where you can search for the specific CPT code and review its status and reimbursement details. Additionally, MACs, which are regional contractors responsible for processing Medicare claims, may have specific guidelines or local coverage determinations (LCDs) that affect the reimbursement of CPT code 43260.
Therefore, to confirm if CPT code 43260 is reimbursed by Medicare, it is essential to review both the MPFS and any relevant MAC guidelines.
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