CPT code 43278 is for the procedure of ablating a lesion during an endoscopic retrograde cholangiopancreatography (ERCP) while dilating.
CPT code 43278 is used to describe a procedure where a healthcare provider performs an endoscopic retrograde cholangiopancreatography (ERCP) to ablate a lesion while also dilating the area. This procedure typically involves the use of specialized instruments to remove or destroy abnormal tissue in the bile ducts or pancreatic ducts, while simultaneously widening the ducts to improve the flow of bile or pancreatic juices.
For CPT code 43278, which pertains to ERCP lesion ablation with dilation, 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 apply if the procedure was more complex or took significantly longer than usual.
2. Modifier 51 (Multiple Procedures): Used when multiple procedures are performed during the same session. This modifier indicates that the procedure was one of several performed.
3. Modifier 52 (Reduced Services): Used when a service or procedure is partially reduced or eliminated at the physician's discretion. This could apply if the full extent of the procedure was not necessary.
4. 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. This is particularly relevant if multiple procedures are performed that are not typically reported together.
5. 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.
6. 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.
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 related procedure is performed during the postoperative period of the initial procedure.
8. 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.
9. Modifier 80 (Assistant Surgeon): Used when an assistant surgeon is required during the procedure.
10. Modifier 81 (Minimum Assistant Surgeon): Used when a minimum assistant surgeon is required during 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): Used when a non-physician provider assists in the surgery.
These modifiers help provide additional information about the circumstances under which the procedure was performed, ensuring accurate billing and reimbursement.
The CPT code 43278 is reimbursed by Medicare, but the reimbursement is subject to specific conditions outlined in the Medicare Physician Fee Schedule (MPFS).
The MPFS provides a comprehensive list of services covered by Medicare and the corresponding payment rates. Additionally, the reimbursement for CPT code 43278 may vary depending on the local policies and guidelines set by the Medicare Administrative Contractor (MAC) for your region.
It is essential to consult the MPFS and your regional MAC to determine the exact reimbursement details and any additional requirements that may apply.
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