CPT code 43265 is a medical billing code for ERCP lithotripsy, a procedure to break up stones in the bile ducts.
CPT code 43265 is used to describe the procedure of endoscopic retrograde cholangiopancreatography (ERCP) with lithotripsy, specifically for the fragmentation of calculi (stones) in the bile ducts or pancreatic ducts. This procedure involves the use of endoscopy to visualize the ducts and the application of lithotripsy techniques to break down stones, facilitating their removal and alleviating blockages.
For CPT code 43265 (ERCP lithotripsy calculi), 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 complications or unusual circumstances.
2. Modifier 26 - Professional Component: This modifier is used when only the professional component of the service is being billed, such as the interpretation of the procedure.
3. Modifier 51 - Multiple Procedures: Apply this modifier if multiple procedures were performed during the same session. This helps in indicating that the procedure was one of several performed.
4. Modifier 52 - Reduced Services: Use this modifier if the procedure was partially reduced or eliminated at the physician's discretion.
5. Modifier 59 - Distinct Procedural Service: This modifier is 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: Apply 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: This modifier is used 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: Apply 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: Use this modifier if an assistant surgeon was required during the procedure.
11. Modifier 81 - Minimum Assistant Surgeon: This modifier is used 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 necessary 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 when these non-physician practitioners assist in the surgery.
These modifiers help in providing additional information about the circumstances under which the procedure was performed, ensuring accurate billing and reimbursement.
When determining if CPT code 43265 is reimbursed by Medicare, it is essential to consult 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 maximum fees Medicare will pay for various services, and it is updated annually.
To verify if CPT code 43265 is reimbursed, you should:
1. Check the MPFS: Access the latest version of the MPFS to see if CPT code 43265 is listed and to review the associated reimbursement rates.
2. Consult Your MAC: Each MAC may have specific guidelines and coverage determinations that can affect reimbursement. Contact your regional MAC or visit their website to confirm if CPT code 43265 is covered and to understand any additional requirements or documentation needed for reimbursement.
By following these steps, you can accurately determine if CPT code 43265 is reimbursed by Medicare.
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