CPT code 43800 is for the surgical reconstruction of the pylorus, a part of the stomach, often performed to treat various gastrointestinal conditions.
CPT code 43800 is the code used for the surgical procedure known as reconstruction of the pylorus. This procedure typically involves repairing or reconstructing the pyloric region of the stomach, which is the area that connects the stomach to the small intestine. It is often performed to address conditions such as pyloric stenosis or other abnormalities affecting the pylorus, ensuring proper passage of food from the stomach into the intestine.
For the CPT code 43800 (Reconstruction of pylorus), 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.
2. Modifier 51 - Multiple Procedures: Indicates that multiple procedures were performed during the same surgical session.
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 a 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 62 - Two Surgeons: Indicates that two surgeons worked together as primary surgeons performing distinct parts of a single reportable procedure.
7. Modifier 66 - Surgical Team: Used when a complex procedure requires the services of several physicians, often of different specialties, working together as a team.
8. Modifier 76 - Repeat Procedure by Same Physician: Indicates that a procedure or service was repeated by the same physician subsequent to the original procedure or service.
9. Modifier 77 - Repeat Procedure by Another Physician: Indicates that a procedure or service was repeated by another physician subsequent to the original procedure or service.
10. 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 requires a return to the operating room for a related procedure during the postoperative period.
11. Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period: Indicates that the performance of a procedure or service during the postoperative period was unrelated to the original procedure.
12. Modifier 80 - Assistant Surgeon: Used when an assistant surgeon is required during the procedure.
13. Modifier 81 - Minimum Assistant Surgeon: Indicates that a minimum assistant surgeon was required during the procedure.
14. Modifier 82 - Assistant Surgeon (when qualified resident surgeon not available): Used when an assistant surgeon is required and a qualified resident surgeon is not available.
15. 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.
These modifiers help provide additional information about the circumstances under which the procedure was performed, ensuring accurate billing and reimbursement.
When determining if CPT code 43800 (Reconstruction of pylorus) 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 healthcare services, including surgical procedures.
To verify reimbursement for CPT code 43800, healthcare providers should:
1. Check the MPFS: Access the latest version of the Medicare Physician Fee Schedule to see if CPT code 43800 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 whether CPT code 43800 is reimbursed. MACs are responsible for processing Medicare claims and can provide detailed information on coverage policies.
By cross-referencing both the MPFS and your MAC's guidelines, you can determine if CPT code 43800 is eligible for Medicare reimbursement.
Discover how MD Clarity's RevFind software can enhance your revenue cycle management by accurately reading your contracts and detecting underpayments down to the CPT code level and by individual payer. For instance, RevFind can identify discrepancies in payments for CPT code 43800. Schedule a demo today to see how RevFind can help you ensure you're receiving the full reimbursement you deserve.
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