CPT code 43264 is a medical billing code used for the procedure of removing duct stones during an endoscopic retrograde cholangiopancreatography (ERCP).
CPT code 43264 is used to describe the procedure of endoscopic retrograde cholangiopancreatography (ERCP) specifically for the removal of duct calculi, or stones, from the bile duct. This procedure involves the use of an endoscope to access the bile duct and extract any obstructive stones, helping to alleviate blockages and restore normal bile flow.
When using CPT code 43264 for ERCP to remove duct calculi, several modifiers may be applicable depending on the specific circumstances of the procedure. Below is a list of potential modifiers and the reasons for their use:
1. Modifier 22 - Increased Procedural Services
- Use this modifier if the procedure required significantly more work than typically required. This could be due to unusual anatomy, extensive adhesions, or other complicating factors.
2. Modifier 51 - Multiple Procedures
- Apply this modifier if multiple procedures were performed during the same session. This indicates that more than one procedure was carried out, which may affect reimbursement.
3. Modifier 52 - Reduced Services
- Use this modifier if the procedure was partially reduced or eliminated at the physician's discretion. This could occur if the procedure was started but not completed due to patient safety concerns or other factors.
4. Modifier 53 - Discontinued Procedure
- Apply this modifier if the procedure was 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 a procedure or service was distinct or independent from other services performed on the same day. This is often used to bypass National Correct Coding Initiative (NCCI) edits.
6. Modifier 76 - Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional
- Apply this modifier if the same procedure was repeated by the same physician or other qualified healthcare professional.
7. Modifier 77 - Repeat Procedure by Another Physician or Other Qualified Health Care Professional
- Use this modifier if the same procedure was repeated by a different physician or other qualified healthcare professional.
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
- Apply 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 an unrelated procedure was performed by the same physician during the postoperative period of the initial procedure.
10. Modifier 80 - Assistant Surgeon
- Apply 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)
- Apply 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 physician assistant, nurse practitioner, or clinical nurse specialist assisted in the surgery.
These modifiers help provide additional information about the circumstances of the procedure, which can affect billing and reimbursement. Always ensure that the use of modifiers is supported by appropriate documentation in the patient's medical record.
CPT code 43264 is reimbursed by Medicare. The 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 the provider's region, medical necessity documentation, and any applicable local coverage determinations (LCDs) or national coverage determinations (NCDs).
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