How accurately do you capture the severity of upper GI conditions and use the associated codes? Gastroesophageal reflux disease (GERD) is a common gastrointestinal disorder in the US, affecting around 20% of the population. Therefore, the increasing demand for gastroenterologists is understandable.
But, with their busy schedules, most doctors find it difficult to manage accurate billing and coding. Coding challenges often arise due to overlapping conditions and treatments, which add to their frustration. Facing the same problem? We are here to simplify coding by explaining one code at a time. Today, our topic of discussion is the popular CPT code 43235.
43235 CPT Code – Description
CPT code 43235 refers to a popular esophagogastroduodenoscopy (EGD) procedure. In simple words, it specifies a minimally invasive diagnostic procedure, involving the use of an endoscope, in the upper gastrointestinal (GI) tract.
During this procedure, gastroenterologists insert a long, thin tube with a light and camera through the patient’s mouth to the esophagus, stomach, and duodenum (the first part of the small intestine).
The primary reason? To examine the GI tract and identify disorders and problems, including gastroesophageal reflux disease! The procedure may also include gathering specimens by brushing or washing the examined area. However, you can use CPT code 43235 for the base diagnostic examination even if the doctor does not collect any specimen.
Scenarios Where CPT Code 43235 is Applicable
Many healthcare providers confuse CPT code 43235 with CPT code 43239 and experience claim denials. If you want to use this basic EGD code accurately, look at the following applicable scenarios:
Unexplained Abdominal Pain
You can use CPT code 43235 whenever doctors perform an esophagogastroduodenoscopy procedure to investigate upper GI tract issues. Assume a 32-year-old woman visits a gastroenterologist due to persistent upper abdominal pain.
After a thorough evaluation, the doctor performs an EGD to visually examine the patient’s upper GI tract and identify the actual problem. He only performs the basic diagnostic test and does not collect any specimens. Therefore, he uses CPT code 43235 to bill for this procedure.
Complicated Gastroesophageal Reflux Disease (GERD) Evaluation
While you can diagnose uncomplicated GERD without a test, what should you do if a patient exhibits complicated or alarming symptoms? Let’s consider this scenario:
Assume a 54-year-old man visits an outpatient clinic with alarm symptoms, including unexplained rapid weight loss, bleeding, persistent nausea and vomiting, and difficulty swallowing (dysphagia).
After a thorough assessment and review of his medical history, the doctor discovers that the patient has a history of chronic GERD. The gastroenterologist performs an esophagogastroduodenoscopy to examine the patient’s upper GI tract, from the esophagus to the upper part of the small intestine.
This diagnostic procedure allows the doctor to diagnose esophagitis (inflammation of the tissues lining the esophagus) without collecting any specimens. As a result, the billing team uses CPT code 43235 to report this test to the appropriate payer.
Diagnosing Gastritis
A 45-year-old arrives at a gastroenterology clinic with persistent tiredness, anemia, and tingling or numbness in her limbs. The doctor suspects gastritis and performs an esophagogastroduodenoscopy to confirm this suspicion.
Since he only performed a basic test to visualize the upper GI tract, he used CPT code 43235 to document and report this procedure.
Applicable Modifiers for CPT Code 43235
Modifiers are essential in certain circumstances. Since CPT code 43235 refers to a global diagnostic procedure, you cannot apply modifier 26 and TC with this code. So, which modifiers are appropriate with this EGD code? Let’s find out!
Modifier 22
You can use this modifier if the EGD procedure requires additional effort and work. Modifier 22 refers to increased procedural services involving significant effort, intensity, and time.
For example, advanced endoscopic techniques may be necessary if you spend more than 30 minutes analyzing the GI tract due to anatomical issues, such as strictures (narrowing of the esophagus) that make it difficult to access the target area. In such a case, you can use modifier 22 to report these additional measures.
Modifier 52
You can also apply modifier 52 to indicate a reduced service. For example, if a physician decides to perform a less extensive EGD, only examining the patient’s esophagus and stomach and not his duodenum, he can append modifier 52 to CPT code 43235.
Modifier 53
Modifier 53 is also applicable in extenuating circumstances. For example, if a gastroenterologist started the procedure after administering anesthesia but had to abandon it in the middle due to a significant risk to the patient’s safety.
Modifier 59
You can append modifier 59 if the EGD procedure is distinct and separately identifiable from other procedures or services performed on the same day. In short, you can use this two-digit code to report CPT code 43235 alongside another code that is not typically reported together but is appropriate in this specific case.
However, be very careful while using this modifier. Check the NCCI edits and only use it when no other alternative modifier is available.
CPT Code 43235 – Billing & Reimbursement Guidelines
Accidentally paired CPT code 43235 with 43239? Don’t make the same mistake again! Follow our billing and reimbursement guidelines for this basic EGD test to receive appropriate payments.
Justify Medical Necessity
Thorough documentation is essential for justifying the medical necessity of CPT code 43235. Therefore, document the reason for performing an EGD procedure in the patient’s medical records.
Include the patient’s symptoms, detailed descriptions of the procedure, including endoscope insertion, findings, such as ulcer, GERD, or gastritis, and medical decisions. Also, mention if you collected specimens via washing or brushing during this procedure.
Apply Applicable Modifiers (If Necessary)
If you want to report additional details about CPT code 43235, choose the correct modifier. Use modifier 22 if the procedure required greater effort and time, append modifier 52 to report reduced service, 53 to collect partial payment for discontinued service, and 59 to specify that the EGD procedure was distinct from others performed on the same day.
Avoid Unbundling
Avoid fraudulent practices, such as inappropriately separating services that should be billed under a single code. Here, it means billing CPT code 43235 with CPT code 43239. Insurance companies will view this as your attempt to increase reimbursements and may either deny your claim or impose a penalty.
Verify & Follow Payer-Specific Rules
Compliance is the most important factor in medical billing. Always follow payer-specific guidelines while billing for CPT code 43235. This includes checking NCCI edits, verifying insurance coverage and pre-authorization requirements, and reviewing the payer’s fee schedule for reimbursement rates to avoid billing issues and disputes.
Stay Updated on the Latest Coding & Billing Guidelines
Insurance guidelines and requirements are often updated. Therefore, you should keep up with the latest billing and coding policies while using CPT code 43235 to avoid claim denials. Regularly review and educate your billing staff on the payers’ changing requirements, including Medicare and Medicaid, to receive complete payments.
Conclusion
To summarize, 43235 is a popular gastroenterology CPT code, pointing towards an esophagogastroduodenoscopy (EGD) procedure. This minimally invasive diagnostic test allows healthcare providers to diagnose several upper GI tract disorders, including the most prevalent gastroesophageal reflux disease (GERD).
Unfortunately, many healthcare providers face claim denial for this procedure because of coding confusion and unbundling. To help you avoid such problems, we have simplified CPT code 43235 in our blog and covered applicable scenarios. You can follow our reimbursement and billing guidelines to receive complete payments. Or partner with us to receive comprehensive gastroenterology billing services, including medical coding.
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