CPT codes precisely explain the procedure that physicians perform on their patients. These codes eliminate the need to provide a thorough step-by-step explanation in documents and reports. CPT code 43239 is the most commonly used in gastroenterology.
This blog covers all the details about CPT code 43239 that you will probably need to know while billing for your services. We have covered its description, some scenarios where this code is relevant, applicable modifiers, and billing guidelines. So, let’s dive into it.
CPT Code 43239 – Description
CPT code 43239 is a medical procedural code maintained by the American Medical Association (AMA) under the category “Esophagogastroduodenoscopy Procedures.”
This code describes an esophagogastroduodenoscopy (EGD) with a biopsy. It diagnoses and manages disorders affecting the upper gastrointestinal (GI) tract, particularly the stomach, duodenum, esophagus, and/or jejunum.
In this process, the physician passes a flexible endoscope through the mouth and into the esophagus, stomach, and duodenum. He then removes one or more tissue biopsy specimens for diagnostic analysis. However, CPT code 43239 does not include hemorrhage control, polypectomy, and foreign body removal.
Scenarios Where CPT Code 43239 is Applicable
The esophagogastroduodenoscopy procedure, or upper endoscopy, is a process performed to view the inside of your esophagus, stomach, and duodenum, which is the upper part of your small intestine. Providers identify and treat digestive tract issues such as coeliac disease, acid reflux, and stomach ulcers with this procedure.
To further understand why and how CPT code 43239 is applied in certain situations, you can read a few scenarios below:
Acid Reflux & GERD
Acid reflux is common if you have had a large meal or lie in bed to rest right after a meal. It can be managed at home. However, this can escalate to chronic acid reflux, which is also known as gastroesophageal reflux disease (GERD).
Let’s imagine that a 50-year-old obese man suffers from acid reflux after meals. This condition became more severe with time. He now experiences a burning feeling (heartburn) more frequently, which has started to affect his sleep. Additionally, he has lost several pounds without consciously working for weight loss. The physician asks him to get an upper endoscopy for further diagnosis. In this case, the provider will apply CPT code 43239
Barrett’s Esophagus
Since we have discussed GERD, the risk of Barrett’s esophagus is higher in people with GERD. Even though it does not have any specific symptoms, its symptoms probably resemble GERD.
Let’s say a 60-year-old man visits the clinic complaining of persistent chest pain and heartburn. The physician performs an examination and discovers that the patient is having trouble swallowing and has a sore throat. He orders an upper endoscopy right away to gain a better understanding of his condition. Hence, the practitioner will bill the endoscopy using CPT code 43239.
Peptic Ulcers
It is estimated that almost 5–10% of people get peptic ulcer disease (PUD) globally at some point in their lives. The most common symptoms of this disease are abdominal pain or dyspepsia (indigestion in simple terms).
Imagine that a patient in his late thirties visits the clinic with severe abdominal pain. He explains the symptoms he has been experiencing, like a mild fever with dizziness and blood in his stool. The physician suggests a biopsy through upper endoscopy for the final diagnosis. Therefore, CPT code 43239 will be applied in this scenario.
Celiac Disease
Celiac disease is an immunological response to gluten consumption that damages the small intestine over time. It can occur at any age in your lifetime. The disease is more common in white people and those of Northern European ancestry.
Let’s assume a patient who goes to the clinic with abdominal pain and gastric issues. He feels fatigued all the time. Upon investigation, the physician finds out about his excessive gluten intake. The physician suggests an instant endoscopy with a biopsy of the small intestine to identify the level of damage to the patient. You can claim the services of upper endoscopy under CPT code 43239.
Crohn’s Disease
Crohn’s disease is common. More than three-quarters of a million people suffer from this disease in the USA.
Suppose a patient visits a gastro clinic with abdominal pain, fever, and mouth ulcers. He tells the physician that there has been a decline in his appetite for the past few months, which has caused him to lose weight. Now, what is worrisome is that he is passing bloody stool, which made him rush to the clinic. The physician orders an upper endoscopy to obtain a clearer image of his condition. In this situation, CPT code 43239 will be used for reimbursement.
Applicable Modifiers for CPT Code 43239
Owing to the intricacy of the diagnostic procedure, unforeseen events that necessitate prompt action may arise, such as a patient’s worsening health following local anesthesia. The provider must abandon the procedure in this situation.
Healthcare providers can use a modifier to claim payment for the rendered services under unanticipated circumstances. Some relevant modifiers with CPT code 43239 are listed below.
Modifier 51
Modifier 51 explains multiple procedures in the same session. You can append this modifier with CPT code 43239 when the upper endoscopy with biopsy is performed on the same day or in the same session as other distinct services, e.g., removing a skin lesion and performing the esophagogastroduodenoscopy.
Modifier 53
This modifier refers to a surgical or diagnostic treatment initiated but discontinued because of extenuating circumstances or conditions that may endanger the patient’s health. For modifier 53 to be relevant, the procedure must be discontinued after anesthesia administration.
For example, you can append this modifier if the process is started by giving local anesthesia to a patient, but due to bleeding or a reaction to the anesthesia dose, the procedure is discontinued.
Modifier 59
Modifier 59 refers to a distinct procedural service. This modifier specifies that a procedure or service is distinct from another procedure carried out on the same service date. However, this modifier is often overused. So, it is better to append its specific subsets – modifiers XE, XP, XS & XU.
Modifier XE
Modifier XE refers to a distinct service that was performed in a separate session on the same patient and the same date of service.
Modifier XP
Modifier XP refers to a distinct service that was performed in the same session on the same patient and on the same date of service but by a different practitioner.
CPT Code 43239 – Billing & Reimbursement Guidelines
The following are some billing guidelines that must be adhered to before filing a claim for CPT code 43239:
Provide Proper Documentation
Documentation is the strongest and primary defense against claim denials. You must ensure that every document you submit for compensation is complete and accurate. Additionally, your documentation must include the patient’s diagnosis and support the medical need for the procedure.
Pair with the Correct Diagnostic Codes
While CPT codes indicate a procedure performed on a patient, diagnostic codes define the patient’s condition. Therefore, your diagnostic codes and CPT codes must match when billing. The following are a few typical ICD-10 diagnostic codes that pair well with CPT code 43239:
- K21.9 (Gastroesophageal reflux disease without esophagitis)
- K22.9 (unspecified esophagus disease or the gullet)
- K29.00 (Acute gastritis without bleeding)
- K31.89 (Other diseases of the stomach and duodenum)
- C15.9 (unspecified cancer of the esophagus)
Follow Payer Guidelines
Each payer has its own set of guidelines and timeline for payment. Therefore, before submitting claims for reimbursement, a biller must confirm everything with the payer and cross-check that all billing requirements are fulfilled.
Append Correct Modifiers
As a medical biller, you must be aware of the correct use of every modifier. Failure to add the appropriate modifier will result in claim denials, ultimately leading to reduced cash flow.
Conclusion
CPT code 43239 reports an upper gastrointestinal endoscopic examination with a biopsy of one or more tissues. The primary purpose of this procedure is to diagnose gastrointestinal disorders like acid reflux, Crohn’s disease, and peptic ulcers. However, the physician must be aware of the billing best practices and changes in payers’ policies to obtain accurate and complete reimbursements.
For this purpose, you can hire gastroenterology billing services that ensure correct coding, compliance with payer policies, and thorough documentation.
