CPT codes are universal codes that document the procedures and medical services performed by physicians. CPT codes have helped a lot in maintaining health records and undergoing an efficient billing and reimbursement process. CPT codes facilitate the maintenance of medical records in clear and accurate versions. Each CPT code represents a specific medical service rendered to the patients. CPT 43235 and 43239 hold significance in gastrointestinal procedures. These procedures can be both therapeutic and diagnostic, and specific codes are assigned accordingly to medical bills.
In this article, we will discuss the difference between CPT codes 43235 and 43239, as well as their clinical indications and reimbursement policies. The basic concept of the Esophagogastroduodenoscopy (EGD) procedure, which is defined by these codes, will also be explained in this guide.
What is the difference between CPT 43235 and 43239 Code?
In the coding world, CPT codes are divided into many families. Each family has one parent code, which describes the basic procedure performed. This code defines the description of that procedure, its clinical indications, and related services. Each parent code has some child code that defines the additional services provided along with the main procedure defined by the parent code. This is how a family system of CPT codes works in the medical billing and coding world.
Code 43235 is the parent code that defines the Esophagogastroduodenoscopy (EGD). It is a diagnostic approach to examine the structures from the esophagus to the duodenum. EGD is a flexible, transoral procedure to examine the alimentary canal for the evaluation of the esophagus, stomach, and duodenum.
Code 43239 defines the Esophagogastroduodenoscopy (EGD) along with a biopsy of the surrounding tissues. A biopsy is done of single or multiple surrounding tissues to examine for tumors, ulcers, and many other pathological abnormalities.
Concept of Child Codes
In the case of CPT code 43239, 43235 is the parent code that defines the transoral flexible Esophagogastroduodenoscopy (EGD) as the main procedure. There are also many child codes, like 43239, which define the associated services provided along with the parent code.
- 43236: Upper gastrointestinal endoscopy with biopsy
- 43238: Upper gastrointestinal endoscopy with control of bleeding
- 43250: Upper gastrointestinal endoscopy with placement of a stent
Understanding of Esophagogastroduodenoscopy (EGD)
EGD is a procedure that includes esophagoscopy and upper gastrointestinal endoscopy. In this procedure, a tube is inserted through the mouth into the esophagus. The camera is attached to the tube to visualize the mucosa of the canal for any abnormalities. The examination starts from the cricopharyngeus muscle and moves to the gastroesophageal junction in esophagoscopy. In upper gastrointestinal endoscopy, the stomach and proximal part of the duodenum are also examined. The simple EGD is performed for diagnostic purposes, and no therapeutic interventions are performed. This is specified by the parent CPT code 43235.
Code 43239 also includes biopsy, which involves the removal of a small portion of suspicious tissue and sending it to the laboratory for any underlying pathological abnormalities. It is performed to know the pathology of a suspicious lesion, any type of ulcer, and inflammation that are visualized during EGD.
Other child codes can also be mentioned in the medical bills if therapeutic interventions are done during the EGD procedure. For instance, if EGD is done to locate an area of bleeding and control it, then CPT code 43238 will be assigned as a child code.
Key differences between CPT Code 43239 and 43235
Primary Purposes
EGD of 43235 is solely done for diagnostic purposes. The stomach, duodenum, and esophagus are examined in case of complaints like dysphagia, pain, heartburn, and bleeding. For 43239, EGD is done for both diagnostic and therapeutic purposes. Biopsy is also taken for further lab investigation. EGD is done for therapeutic purposes also.
Less time is involved in diagnostic EGD. 15-30 minutes are enough. A biopsy is a complex process that takes time. Time exceeds the 30 min threshold.
Indications & Procedure Type
CPT code 43235 defines a simple procedure without any invasion. Therefore, reimbursement rates are low as compared to code 43239. 43239 involves biopsy, which is performed by the experts, leading to higher reimbursement rates.
Only visual investigation is done for code 43235, so billing is simple. However, billing is complex for biopsy as it needs authentic supporting documents. Sometimes, modifier 59 is used.
Reimbursement & Billing Complexity
Unexplained symptoms are primary indications for 43235. Symptoms include pain, bleeding, inflammation, heartburn, and difficulty in swallowing. EGD, along with biopsy, is done for suspicious conditions like cancer, Barrett’s esophagus, ulcers, or lesions.
43235 EGD is solely done for diagnostic purposes. The stomach, duodenum, and esophagus are examined in case of complaints like dysphagia, pain, heartburn, and bleeding. For 43239, EGD is done for both diagnostic and therapeutic purposes. Biopsy is also taken for further lab investigation. EGD is done for therapeutic purposes also.
Documentation Requirement
Unexplained symptoms are primary indications for 43235. Symptoms include pain, bleeding, inflammation, heartburn, and difficulty in swallowing. EGD, along with biopsy, is done for suspicious conditions like cancer, Barrett’s esophagus, ulcers, or lesions.
43235 EGD is solely done for diagnostic purposes. The stomach, duodenum, and esophagus are examined in case of complaints like dysphagia, pain, heartburn, and bleeding. For 43239, EGD is done for both diagnostic and therapeutic purposes. Biopsy is also taken for further lab investigation. EGD is done for therapeutic purposes also.
Risks Involved
Diagnostic EGD can cause sore throat, allergy, and mild discomfort after the procedure. They are common and can be relieved by medicines. Bleeding, infection, and perforation are the complications that arise due to the invasive nature of the procedures billed under 43239.
For 43235, no follow-up or recovery protocols are required as there is no injury. While biopsy is an invasive procedure, time is needed for recovery. Follow-up is also required to rule out any infection and injury.
Best Practices for Accurate Billing and Reimbursement
Verification of Insurance Coverage
Before proceeding with EGD, the patient’s insurance coverage should be checked whether his insurance covers this procedure or not. If not, he should be informed beforehand about the out-of-pocket EGD service. If he has Medicare insurance, then he should obtain an Advance Beneficiary Notice (ABN) to get the desired service.
Pre-Procedure Authorization
Even if the medical service is covered by the insurance company, many insurers ask for pre-authorization before performing endoscopic investigations. Insurers are contacted, and clinical indications, symptoms, history, and recommendations are provided to get permission for this procedure.
Apply Correct Coding Practices
Effective coding and billing are cornerstones of the whole process. An expert team or third party should be hired for this task. There are some rules for billing CPT codes 43235 and 43239, which should be kept in mind to avoid claim denials. According to Medicare policies, modifiers can be used along with the CPT code in case two or more relevant or irrelevant procedures are being undertaken simultaneously. Modifier 59 is used if both diagnostic and therapeutic EGDs are performed. Modifier 59 denotes two separate and distinct procedures.
Modifier 51 is used when multiple procedures are performed at a single time. It shows that the second procedure is performed in conjunction with the first one. Modifiers should be used accurately to give a clear idea of services rendered.
Bundling and unbundling scenarios should also be taken care of for CPT codes 43239 and 43235. There is a bundling rule that if a biopsy is performed in the EGD procedure, then it involves a diagnostic examination (code 43235) as well, but only CPT code 43239 is billed. If you bill both codes separately for diagnostic and therapeutic services, then the claim can be denied. They are bundled together, and unbundling results in a potential revenue leak.
These codes also do not cover the follow-up visits and visits for the interpretation of biopsy results. These visits will be billed separately; therefore, they are known as “zero-day global” services.
Clear & Detailed Documentation
It is recommended that every piece of information, from clinical indications and findings to interpretations, be documented. Complete and accurate documentation results in a smooth reimbursement process. Documentation is also necessary for undergoing audits and records scrutiny. Document complications, procedural details, time duration, and biopsy details to support billing for CPT codes 43235 and 43239.
Monitor Denials & Rejections
Lack of authorization, incorrect coding, and missing documentation can lead to claim denials and financial instability. The billing team should be competent in addressing the objections raised by the players and clearing them as soon as possible. Core issues should be detected at once if you are experiencing a chain of claim denials and try to get the solution. In this way, you can bring some potential financial stability.
Conclusion
Endoscopy of the gastrointestinal tract, including codes 43235 and 43239, serves the purpose of examining the structural and functional anatomy of the alimentary canal, starting from the esophagus to the proximal part of the duodenum.
The parent code for Esophagogastroduodenoscopy is assigned as code 43235, which works as a diagnostic procedure, whereas the child code 43239 is assigned for Esophagogastroduodenoscopy for both diagnostic and therapeutic purposes, and biopsy is also included in it. There are so many key differences between these two codes.
Diagnostic EGD is more non-interventional and less complicated and normally takes between 15-30 minutes to complete. Fewer reimbursement rates and fewer document requirements are required. Although there are risks associated with EGD with biopsy, for instance, bleeding and perforation, it is a complicated invasive process. A lot of time is used in the conduction of this process, and high levels of expertise are required. Some ways of improving billing and reimbursement include verifying insurance, seeking physician pre-approval, coding the claim correctly, and observing claim denials.