CPT 43239

(2022) CPT 43239 – Description, Guidelines, Reimbursement, Modifiers & Examples

CPT 43239 defines the insertion of a flexible endoscope through an oral route for direct visualization and to take tissue samples from the esophagus, stomach, and/ or duodenum.

Physicians can take single or multiple tissue biopsies during the procedure from different sites of the upper gastrointestinal tract.

These biopsied samples are then sent to a laboratory for microscopic analysis. Based on the results, the physician addresses the underlying issue and prescribes a care plan accordingly.

CPT 43239 Description

An endoscope is an optical/ tubular tool used for direct visualization inside the deep hollow organs of the body, preferably by natural openings, i.e., the oral route or the anal route.

The types of Endoscopes used in such procedures are designed flexibly to effortlessly pass through the narrow collapsible structure of the gastrointestinal tract.

There is a high risk of damaging the internal lining of tubal structures involved while performing the endoscopic procedures with a rigid endoscope.

The most common problem while performing an endoscopic procedure is ‘ulceration,’ leading to severe complications.

So, to minimize the chances of any damage to the internal structure of the gastrointestinal tract, it is always preferred to use flexible tubes over rigid types of tubes. 

A biopsy is described as removing a tiny piece (tissue) from any internal or external body organ. The key purpose of such procedures is to detect any pathological changes due to an underlying cause. 

In outpatient settings, most of the time, ‘Needle biopsies’ are performed. They are minimally invasive, and very few preparations are required to accomplish the procedure. So, they are preferred over the other methods of taking tissue samples which may require any open surgical procedures.

Different Gauges of needle syringes are used to take samples. The selection of an appropriate gauge of needle syringe is highly dependent on the organ or site from where the tissue for examination is required.

If the site is in the deep plane of the body, it is carried out with the help of ultrasound or fluoroscopy to further minimize the risk of adjacent tissue damage.

CPT 43239 fully includes the bleeding control after the biopsy because the gastrointestinal system is a highly perfused system of the body.

And there are increased probabilities of bleeding from the biopsy site, which can be easily controlled with electrocauterization during the same procedure. So, after taking a biopsy or during the procedure, the bleeding control should not be confused as a separate service.

Because as per description, the bleeding control during or after the biopsy is wholly included with the primary procedure.

But occasionally, due to the patient physical condition or other physiological changes in the patient’s body, it is hard to get biopsies from the target site, i.e., stricture of the esophagus, acute gastritis, or hiatus hernia.

In such cases, it may require more than usual efforts of the provider to reach the target site, so we can append certain modifiers to make the rendering physician eligible for increased procedural services that will increase reimbursement.

In What Conditions Is This Procedure (CPT 43239) Performed?

Whenever a physician needs to discover the extent of damage done to the tissues of upper GI tract organs, he orders tissue biopsy.

The most common procedure indications (CPT 43239) are chronic heartburn, pain in the upper abdomen, unexplained anemia, unexplained weight loss, Crohn’s disease, and peptic ulcer disease.

While performing the procedure (CPT 43239), the provider first administers the local anesthetics and mild sedatives to manage pain and gag reflex.

A few risks and complications are associated with the procedure (CPT 43239), i.e., GI bleed and throat irritation. Sometimes, this procedure may lead to severe complications. But in general, it is considered a very safe and effective procedure.

The recovery time is very quick, and the patient can start doing his routine activities after 24 hours of the procedure.

Some patients are at high risk of developing serious GI disorders. For example, patients with portal hypertension, GERD, Cirrhosis, Obesity, and family history of GI Cancer. For such patients, early screening is very helpful.

The physician may take tissue samples (CPT 43239) to detect any early changes in the normal flora of the gastrointestinal tract.

Billing Guidelines And Reimbursement Policy

The billing guidelines and reimbursement policy for CPT 43239 are governed by appropriate usage of Modifiers, Place of services, Prior authorization, and Medical Necessity as per the state LCD (Local Coverage Determination). 

Both government payers (Medicaid or Medicare) and commercial payers have set slightly different rules. So, the physician’s office must get prior authorization from the respective insurance.

Advance beneficiary notice (ABN) should be presented before providing the service. If insurance denies the service at later stages, it can be billed and get reimbursed from the patient.

Note: For some insurances, for instance, Cigna and BCBS, the submission of the claim also require a prior authorization number along with the other necessary details.

The prior authorization number can be received with prior approval from the respective insurance.

There must be a valid Medical Necessity for a prior authorization number, and all forms must be fulfilled. The claim may be rejected if the prior authorization number is not submitted.

While performing EGD with biopsy (CPT 43239), moderate sedation is required to ease the procedure. This service is separately billable and is not included in the benefits of upper GI tract procedures.

If the procedure is accomplished under moderate sedation, it should be represented with appropriate 9000 series CPT codes and billed as a separate line item.

Moderate sedation section codes are time and age-dependent. So, this series of CPTs should be chosen with great care. Before code selection, the age or time of CPT must be the same as the patient’s age.

If it does not match with the patient’s age, the claim may be denied for any payments.

As we are familiar with EGD with biopsy (CPT 43239), it can be executed in multiple in-patient settings and outpatient settings such as ASC (Ambulatory surgical center), Urgent Care, Office, Out-patient, and In-patient hospital department.

These locations have their specific place of service (POS) codes, for instance, 22, 21, or 24. These POS codes must be used correctly during the claim submission because this is one of the common reasons for denials.

One should always be referred to LCD (local coverage determination). Based on the researched data, there are different sets of ICD 10 CM codes for each state. So, apposite ICD 10 CM selection as per the LCD policy is another key factor in improving the practice’s first pass ratio.

CPT 43239 Reimbursement

The fee for service (FFS) difference between two CPTs (CPT 43235 and CPT 43239) of the same section is nearly 80$. The fee for service (FFS) for CPT 43235 (describes as EGD without biopsy) is $310.80.

While the fee for service (FFS) for CPT 43239 (describes as EGD with biopsy) is $395.61.

Suppose EGD with biopsy (CPT 43239) is executed and perceived wrongly by the coder or biller and is coded with CPT 43235 (EDG without biopsy). In that case, it will result in underpayment that will affect the practice’s revenue cycle. 

While coding, the importance of LCD (Local Coverage Determination) for a specific state and NCD (National Coverage Determination) should be kept in mind to get higher FPR and maximum reimbursement.

CPT 43239 Modifiers

Modifiers work as a catalyst in a claim. Their absence, when required to present certain circumstances or to override the comprehensive component edit policy, is the leading cause of underpayments or overpayments and denials.

Modifier sequencing plays a key role as one must place pricing modifiers in the first place. After that, one must use eligible payment modifiers and then laterality, if necessary, in a claim during submission.

Laterality modifiers, also called anatomical modifiers, such as ‘LT,’ ‘RT,’ and ’50’. 

Note: Laterality or anatomical modifiers are not valid with CPT 43239.

Pricing modifiers directly affect the payment of the procedure and thus affect the practice’s revenue cycle. By using a pricing modifier, reimbursement of the procedure may get increased or decreased.

For example, modifier 22 (increased procedural services) can be used with CPT 43239. The procedure may require more time and effort than usual, depending on the circumstances.

More effort or time can be due to any on-the-spot or already known complication, such as gastric bleeding, esophageal sphincters, stenosis, or other issues. Modifier 22 should be appended with the procedure code (CPT 43239) in such scenarios.

Modifier 52 is used to reduce the payments of services. For example, such situations can arise when the physician cannot provide complete service as described by the description of the CPT 43239.

In such cases, the physician is not eligible for complete payments of the procedure. Thus, the coder or biller may have to apply modifier 52 to represent reduced services given by the physician.  

In a few cases, the primary reason for the endoscopy is bleeding control. During the procedure, a separate lesion is identified, and now the physician seems necessary to perform its biopsy.

CPT 43255 and CPT 43239 are reported together, in this case. The coder or biller can override the comprehensive component edit using modifier 59 with CPT 43239.

Modifier 59 is a payment-eligible modifier and can be used with CPT 43239. In this way, both CPTs can be made eligible for payment.

If modifier 59 is not applied, insurance may process the procedure with lower RVUS. And that may result in delayed payments of the benefits for multiple services performed on a single day.

Modifier SG is appended with CPT 43239 to represent the procedure performed in an ambulatory surgical center (ASC).

If a surgical assistant assists a primary surgeon during surgery, the coder or biller must append modifier 80.

If a non-physician assistant has assisted the primary surgeon during surgery, the coder or biller must append modifier AS.

Examples

A 43 years old patient came to the provider’s office with severe right upper quadrant pain and pitch-black stool (melena). Upon examination and due to the patient’s family history, the physician decided to go for the EGD under moderate sedation.

During the procedure on retroflection, the physician found a bleeding ulcer. He decided to take biopsies to rule out any malignancy as the patient is positive for a family history of gastric cancer. The provider performed a biopsy. 

A diagnostic EGD turns into a therapeutic EGD with biopsy in the above example. So, the appropriate code selection would be CPT 43239 and the moderate sedation code to represent the service performed.

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