The prevalence of esophageal diseases is high in the USA, which directly impacts the demand for their treatment. According to UConn Health, over 15 million Americans have a swallowing disorder. Its primary reason? Narrowing of the esophagus.
Therefore, we have chosen CPT code 43249 (a gastrointestinal code) for discussion today. It covers an esophagogastroduodenoscopy (EGD) with transendoscopic balloon dilation of the esophagus.
This blog will unfold every detail about CPT code 43249, starting from the basic description of the code to the final billing and reimbursement guidelines.
CPT Code 43249 – Description
CPT code 43249 represents a “flexible, transoral esophagogastroduodenoscopy with trans endoscopic balloon dilation of the esophagus (less than 30 mm diameter)”.
In easy words, the healthcare provider inserts a flexible endoscope through the mouth and down into the esophagus, stomach, and duodenum. During this procedure, the physician inserts a balloon (filled with air or water) of less than 30 mm in diameter into the narrowed section of the esophagus. The patient’s esophagus is gently stretched and widened during this treatment.
Healthcare providers recommend this procedure to treat the narrowing of the esophagus (esophageal strictures). This process dilates the narrowed region, facilitating the swallowing of food and liquids.
Scenarios Where CPT Code 43249 is Applicable
Let’s discuss some applicable scenarios that will further help you understand the correct usage of CPT code 43249.
Esophageal Strictures
The condition known as esophageal stricture causes the swallowing tube to constrict. Up to 75% of esophageal strictures are brought on by chronic acid reflux, while a small percentage are due to esophageal cancer.
Consider a man in his mid-twenties who visits a gastroenterologist with symptoms such as non-cardiac chest pain and difficulty swallowing food. When he attempts to swallow forcibly, he chokes or coughs out the food. His inability to swallow suggests that he may have esophageal strictures. The physician recommends an esophageal dilation. He uses a flexible endoscope to pass a 30-mm-diameter balloon and widen the esophagus. Therefore, CPT code 43249 allows him to bill for his services.
Achalasia
Achalasia (cardiospasm) is a rare condition that occurs when food and liquids cannot pass down the esophagus and into your stomach. In the United States, 10 per 100,000 persons suffer from cardiospasm.
Suppose a 35-year-old man visits the clinic. He tells the physician that he is having heartburn and difficulty swallowing. The food comes back to the mouth if he tries hard. Furthermore, he has lost significant weight during this period. Considering his condition, the physician decides to improve the symptoms of cardiospasm using upper endoscopy with esophageal dilation. In this case, he can apply the CPT code 43249 for reimbursement.
Esophageal Rings
Schatzki Ring (esophageal ring) is an extra tissue on the inside of your lower esophagus. These one or more extra tissues narrow down your esophagus.
Imagine a 28-year-old man visiting the clinic with a complaint of having trouble swallowing food. He tells the physician he is experiencing shortness of breath with chest pain, and he can not swallow food properly. Upon deeply analyzing his condition, the physician suspects that the patient might have esophageal rings. So, he decides to cure the condition via esophageal dilation. In this scenario, CPT code 43249 can be used.
Eosinophilic Esophagitis
Eosinophilic esophagitis (EoE) is a chronic inflammatory condition. Research released by the National Institutes of Health (NIH) says that the frequency of EoE in the USA is between 1 and 5 per 10,000 people.
Let’s take an example of a toddler. Imagine a couple who take their baby to a physician’s clinic. They tell the physician that the baby is refusing to eat, and he vomits when they forcefully feed him. The physician performs a thorough examination and diagnoses the baby with eosinophilic esophagitis. He decides to treat this condition via esophageal dilation. Hence, he can apply CPT code 43249 for reimbursement.
Applicable Modifiers for CPT Code 43249
The following are a few examples of modifiers that are commonly appended to CPT code 43249.
Modifier 53
You can apply modifier 53 if you discontinued a procedure after its initiation due to the patient’s worsening condition. For example, if you started the upper endoscopy with esophageal dilation but could not continue it further because the chances of the patient’s lung failure were increasing as the procedure was advancing, modifier 53 will be applicable in this case. However, you must note that the procedure can only be discontinued after anesthesia administration.
Modifier 59
Modifier 59 is only applied to identify two distinct non-E/M services. This modifier highlights services or treatments that are not typically reported together but are appropriate in specific clinical situations. Its primary purpose is to break the NCCI edits bundling rules. However, due to its overuse, payers recommend using the XE, XS, XP, or XU subsets.
Modifier XE
You can append modifier XE when another service is given to the same patient on the same day of service, but in a separate encounter.
Modifier XS
Modifier XS identifies that a distinct procedure was performed on the same patient on the same day, but on a different structure or a separate organ.
CPT Code 43249 – Billing & Reimbursement Guidelines
Billers must adhere to the following billing and reimbursement guidelines of the CPT code 43249 to minimize the probability of claim denials.
Provide Detailed Documentation
Medicare does not accept or reimburse claims without proper documentation. There are some prerequisites that Medicare has specified for billers that they must fulfill before submitting claims to Medicare or any Medicare Administrative Contractor (MAC). These include:
- The patient’s medical file must include all paperwork.
- This file should be provided to the contractor upon request. According to Title XVIII of the Social Security Act, Section 1833(e), no provider will get payment for a claim that does not have the information required to process it.
- Each page of the record should be readable and contain the patient’s identity details, full name, and dates of service.
- The physician or non-physician practitioner in charge of the patient’s care must have signed the paperwork.
- The medical necessity of the services as specified in this policy must be supported by the documentation in the medical records.
Include Appropriate Diagnostic Codes
According to Section 1862(a)(1)(A) of Title XVIII of the Social Security Act, Medicare will not pay for items or services that are not reasonable and required for the diagnosis or treatment of disease or damage. Hence, your documentation must support diagnostic codes, and the diagnostic codes must justify the procedure’s need. For example, if you are carrying out a treatment of esophageal dilation for a congenital esophageal web, you must cite it with the ICD-10 diagnostic code Q39.4.
Follow Payer Guidelines
Review the payer’s guidelines before submitting claims because there are some services that Medicare does not cover, such as routine treatments. Furthermore, you must cross-check with your patients’ payers before bundling procedures or applying modifiers. This will help you confirm whether they allow the bundling of certain codes or not. Otherwise, you will receive a denial for your claims.
Append Correct Modifiers (when needed)
When necessary, billers should include the appropriate modifiers with CPT code 43249. We suggest that rather than using the more generic modifier 59, use its subsets for enhanced specificity. For instance, if a patient received another service on the same day, you must include the appropriate modifier to explain how the service was distinct from the previous one.
Conclusion
To sum up, CPT code 43249 explains an upper endoscopy with esophageal dilation, which involves utilizing a balloon of less than 30 mm in diameter to widen the esophagus. With a few real-world examples, applicable modifiers, and billing guidelines, we have attempted to clarify the usage of CPT 43249 on the gastroenterology claim forms.
However, if despite our detailed guide, you encounter issues when billing CPT code 43249, we advise hiring professional gastroenterology billing services. Acquiring these services will decrease the rate of claim denials and streamline your billing process.
