Gastroenterology treatments are not only hard to perform, but they are also very challenging to bill. How many times have you finished a long week of complex procedures only to find that your reimbursements don’t reflect the difficult work you actually performed? That’s a common scenario in almost all gastroenterology practices.
One such procedure that is frequently denied by payers is reported with CPT code 43251. Even though the procedure itself is uncomplicated, its billing is not. In this guide, we will discuss how you can ensure the proper use of this code in your claims.
So, let’s start.
CPT Code 43251 – Description
CPT code 43251 is defined as:
“Esophagogastroduodenoscopy (EGD), flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique.”
Sounds hard? Let’s break this down in simpler terms.
Code 43251 is a gastroenterology billing code. It is used for therapeutic esophagogastroduodenoscopy (EGD). In simple terms, EGD is an endoscopic procedure that
visualizes the upper part of the gastrointestinal (GI) tract.
During this procedure, the physician uses a flexible endoscope, inserted through the mouth, to visualize the esophagus, stomach, and duodenum. However, unlike a purely diagnostic EGD (CPT 43235), code 43251 is used when the provider actively removes abnormal tissue, like polyps or tumors. Additionally, the removal of these tissues is performed via the “snare” technique.
To help you understand the process better, here is an explanation of the snare technique.
The snare technique is what distinguishes this code from other similar procedures. What is it? It involves passing a wire loop (the snare) into the GI tract. This is done via the accessory channel of the endoscope. This loop is then placed around the lesion and slowly tightened until the lesion detaches from the base. During the procedure, electrocautery is often used to prevent any bleeding.
An important point to note here is that the entire procedure covered under CPT code 43251 is performed after anesthesia administration. However, the reimbursement for anesthesia is not included in the code, and you will have to bill it separately.
Scenarios Where CPT Code 43251 is Applicable
To clear any confusion, let’s look at a couple of real-world scenarios in which CPT code 43251 can be used:
Dysphagia
For our first scenario, suppose a patient visits a clinic. He complains of increased difficulty in swallowing solid foods. He also shares with the physician that he feels occasional chest discomfort after eating. The physician notes all the symptoms and suspects possible obstruction or abnormal growth in the esophagus. However, to confirm the diagnosis, the physician orders an esophagogastroduodenoscopy (EGD) to visualize the upper digestive tract.
During the EGD, the gastroenterologist finds multiple esophageal polyps. These polyps are the reason for mechanical dysphagia. Hence, the physician removes the polyps using a snare technique. In this case, the billing department can use CPT code 43251 to bill the EGD and the removal of polyps via snare technique.
Benign Tumors
For our second scenario, suppose a patient comes to a clinic with intermittent nausea, upper abdominal fullness, and unexplained weight loss. These symptoms suggest a potential mass or lesion in the upper gastrointestinal tract. However, to confirm and treat the issue, the physician performs an EGD.
During the examination, a benign gastric tumor is discovered along the stomach wall. The physician carefully removes the tumor using a snare technique to prevent further complications. After that, the medical billing department codes and submits the claim for reimbursement. In this case, CPT code 43251 is used.
Applicable Modifiers for CPT Code 43251
The following are some frequently used modifiers with CPT code 43251:
| Modifier | Description | Use Case |
|---|---|---|
| 22 | Increased Procedural Services | Apply this if the procedure is unusually complex or time-intensive. |
| 51 | Multiple Procedures | Indicates that 43251 is one of many procedures performed in the same session. |
| 59 | Distinct Procedural Service | Use this when the procedure is separate from other services performed on the same day, such as a biopsy of a body part. |
CPT Code 43251 – Billing & Reimbursement Guidelines
Here are some additional guidelines to help improve the billing accuracy of your CPT code 43251 claims.
Provide Detailed Documentation
Proper documentation is vital if you want your claims to get reimbursed. For 43251, the supporting documentation must include the following:
- Patient identification information (e.g., complete name, date of service).
- Legible signature of the physician.
- Valid ICD-10 diagnosis code.
- Method of removal (explicitly use the word “snare”).
- Anatomic location (specify where the lesion was found: esophagus, stomach, duodenum).
- Lesion size, morphology (sessile, pedunculated), and appearance.
- Outcome of the procedure and any prescribed medications.
Check the Medicare Reimbursement Rates
The national average Medicare reimbursement rates for CPT code 43251 are:
- Facility setting (hospital outpatient/ASC): $187.61
- Non-facility setting (office): $468.05
However, these rates vary based on the Medicare Administrative Contractor (MAC) locality. So, to find the exact reimbursement rates for your MAC locality, use the PFS Lookup Tool.
Wrapping Up
So, there you have it, a complete guide to CPT code 43251. Let’s recap everything briefly. 43251 represents an EGD procedure in which lesions, polyps, or tumors are removed via the snare technique. For proper reimbursement, you must provide detailed documentation with your claims and append appropriate modifiers where necessary.
If the billing and denials are overwhelming for you, it is better to get help from professionals. Many practices, like MediBillMD, offer expert gastroenterology billing services that are guaranteed to result in higher reimbursements and revenue collection.
