Current Procedural Terminology (CPT) codes are very crucial for healthcare professionals and payers as they play an important role in the medical billing and reimbursement cycle. Why are they so important? Because they are universal codes maintained by the American Medical Association (AMA) to reduce the errors in medical bills and make the billing process efficient. Each code defines some specific medical procedures and services. Therefore, mentioning codes instead of long descriptions of medical services in the bills is more useful. Code 43239 holds significant importance in the digestive system subsection of the CPT code set.
In this article, we will discuss the CPT code 43239 in detail, including its indications, clinical significance, procedure, and reimbursement. We will also discuss the modifiers and costs associated with 43239 in the medical billing.
What is CPT Code 43239?
Code 43239 defines the Esophagogastroduodenoscopy (EGD) along with a biopsy of the surrounding tissues. EGD is a flexible, transoral procedure to examine the alimentary canal from the esophagus to the duodenum. A biopsy is also done of single or multiple surrounding tissues to examine for tumors, ulcers, and many other pathological abnormalities. There are two main components of the 43239 CPT code:
- Esophagogastroduodenoscopy (EGD): This procedure 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 to the gastroesophageal junction in esophagoscopy. In upper gastrointestinal endoscopy, the stomach and proximal part of the duodenum are also examined.
- Biopsy: Biopsy is defined as the removal of a small portion of suspicious tissue and sending it to the laboratory for any underlying pathological abnormalities. It is typically performed when a suspicious lesion, any type of ulcer, and inflammation is visualized during EGD.
Indications for CPT Code 43239
CPT code is required to be used when the patient comes into the outpatient or office with one or two chronic conditions or having new disease symptoms that need to be evaluated and managed. There is always moderate severity of medical decision-making along with detailed history and detailed examination. There are a few components of the 99214 CPT code, which are described below:
1. Diagnostic Purposes
There are many abnormal conditions of the gastrointestinal system, which need to be investigated through the process of EGD. Indications are described in the tabular form:
Gastroesophageal Reflux Disease (GERD) | Acid from the stomach is refluxed back into the oesophagus and causes inflammation and burning sensation. This needs to be evaluated using EGD for underlying pathology. |
Peptic Ulcers | These are the sores which are formed on the inner lining of the mucosal surface of stomach and duodenum. |
Barrett’s Oesophagus | In this condition, normal cells are replaced by abnormal cells due to acid exposure. This problem can lead to cancer and it should be evaluated at once. |
Celiac Disease | It is an immune reaction due to a gluten diet leading to damaged small intestines. |
Esophageal Or Gastric Carcinoma | EGD helps to examine the malignant surface of the alimentary canal. |
Inflammation And Infection | Conditions like gastritis, duodenitis and esophagitis can be detected. |
2. Therapeutic Purposes
EGD is primarily used for diagnostic purposes, but there are some therapeutic conditions in which EGD plays a vital role. Esophagogastroduodenoscopy helps to remove the polyps and or dilate strictures.
3. Screening Of Cancer
Patients with Barrett’s esophagus and GERD are always at risk of developing cancer. Therefore, periodic EGD is performed for such an evaluation.
Clinical Considerations For CPT Code 93234
Risks and complications
While performing EGD, it is important for physicians to know about the risks and potential complications that can develop during the process. At the biopsy site, bleeding is a very common complication, and management plans should be devised immediately to deal with bleeding. Perforation can also be done by the tearing of mucosa using an EGD tube by a less skilled professional with and narrow lumen.
Infection can also develop by the contamination of the camera or EGD tube, which leads to further problems for the patient. All instruments should be disinfected properly, and hygiene protocols should be followed.
Contraindications
Biopsy is not recommended in certain conditions, which can pose serious damage to the organs involved. Biopsy may not be appropriate for bleeding disorders and recent history of gastrointestinal surgery. A biopsy can cause serious, uncontrollable complications.
If a person has uncontrolled pulmonary or CVS problems, then EGD is not performed as sedation and procedure can exacerbate these conditions.
Coding and Billing for CPT Code 43239
1. Reimbursement Consideration
Code 43239 can be billed to Medicare and many other private insurance companies, and everything should be documented for successful audits and to avoid claim denial. Along with CPT code 43239, ICD-10 codes are also mentioned to give information about the underlying indication. ICD-10 codes, which are submitted along 43239, are:
- K21.0: Gastroesophageal reflux disease with esophagitis
- K25.9: Gastric ulcer, unspecified
- K31.89: Other diseases of the stomach and duodenum
- C15.9: Malignant neoplasm of the esophagus, unspecified
These codes provide justification for performing EGD, and these should be documented properly to avoid delays in reimbursement and maintain financial stability.
2. Modifiers Use
CPT code 43239 can be billed once, no matter how many times it is performed in a single visit. Some modifiers are used to correctly elaborate the procedure performed, whether it was complete or not. Some common modifiers are:
- Modifier 26: It is used when a physician has only performed the professional component, i.e., interpretation of results. This does not include the equipment or technical components.
- Modifier 52: It is used if the procedure was partially completed due to unforeseen circumstances.
- Modifier 50: It is known as bilateral surgery modifier and it is used when the procedure is performed on both sides of the body.
- Modifier 62: When two surgeons from different specialties perform the procedure, this modifier is used.
- Modifier 66: When a team of surgeons from the same specialty performs this procedure, it is used.
- Modifier 80/82: It is used when an assistant of a surgeon is taken in the completion of a process.
Supply and Equipment Codes for EGD for CPT Code 43239
The EGD procedure is defined by the code 43239 and it requires a lot of equipment and non-facility direct and indirect services for performing successful Esophagogastroduodenoscopy. Sanitation, safety, and diagnostic protocols should be followed, and each step and equipment used should be documented for effective billing.
Equipment and supplies used in the EGD procedure help to maintain cleanliness, reduce contamination, and enhance the efficiency of the whole process. Important supplies are mentioned below:
- Cleaning & Disinfecting Packs For Endoscopes: Endoscopes should be sanitized and free of contaminants.
- Surgical Caps: Hair contamination can be avoided using caps.
- Non-Sterile Drapes: These are used to avoid infection and protect the patient. A sterile environment during the procedure can be maintained.
- Impervious Gowns: Used to protect healthcare providers from fluid exposure.
- Surgical Masks with Face Shields: They offer dual protection from respiratory droplets and splashes.
- Surgical Shoe Covers: Avoid contamination within the operating area.
- Suction Tubing: Secretions are removed from the tract for a clear and accurate view of EGD.
- Biopsy Forceps & Cytology Brushes: These are used for conducting biopsies from the mucosal tissues.
There are also some supply codes that are supposed to be mentioned along with 43239 in the medical bills to streamline the whole process. Codes are mentioned in the table:
Supply codes | Description |
12345 | Cleaning and disinfecting packs for endoscopes |
67890 | Surgical caps |
23456 | Non-sterile drapes |
34567 | Biopsy forceps |
45678 | Cytology brushes |
Cost components of EGD procedures: Labor, Equipment, & Indirect Expenses
1. Direct Clinical Expenses
Major expenses are clinical labor used while performing the EGD. Work done during the pre-procedure, intra-procedure and post-procedure phases contributes a lot towards the total cost. During the pre-procedure phase, preparing the patient, verifying records, taking consent and setting up equipment need paramedical staff and healthcare professionals.
During the intra-procedure phase, healthcare physicians assist in performing the EGD by guiding the tube induction and taking biopsies. Post-procedure care is also very important in this scenario, i.e., monitoring the patient’s recovery and documentation.
These costs vary depending on the expertise of healthcare professionals, the condition of the patient, and the complexity of the procedure. There are also direct expenses, which are equipment expenses that are used in the process. If we take a rough estimate of the prices of equipment used in the process, then suction machines cost up to $500 – $1,500, endoscope disinfectors cost up to $5,000 – $15,000, and multi-channel flexible scopes cost up to $20,000 – $60,000. These are rough estimates and healthcare professionals should have an exact idea of these costs while deciding the reimbursement rate with the payers.
2. Modifiers Use
In addition to direct costs, there are many indirect expenses and healthcare professionals should have good estimates of those expenses as well to maintain financial stability. Clerical costs like salaries, benefits, and training expenses of the administrative staff maintaining and performing procedure and billing processes.
There are also overhead costs, including office space, equipment periodic maintenance, and operation theatre expenses. They also pose a potential burden on the total cost of performing EGD. Miscellaneous costs for cleanliness, infection control, and fuel bills should also be noted and managed accordingly.
Conclusion
CPT code 43239 is a crucial code used in the field of gastroenterology for performing Esophagogastroduodenoscopy (EGD). This code defines the EGD process for examining and evaluating the condition of mucosa and underlying pathology for any abnormality. It has two components: endoscopic evaluation and undergoing biopsies. It is indicated in various conditions for confirmation of GERD, peptic ulcer, malignancy, inflammation, infection, celiac disease, and Barrett’s esophagus.
Many equipment and tools are used in the whole process. Healthcare professional guidance is very necessary in performing whole tasks. It can be billed for once, and many modifiers are used in the medical bills to provide a better understanding of the nature of the procedure. Clinical and reimbursement considerations should be noted and followed for an effective medical billing and coding process.
FAQ - People Also Asks
EGD with a biopsy includes the examination of the esophagus, stomach, and duodenum with the removal of tissue for pathologic evaluation. In standard EGD, only examination of the walls and lumen is done by taking tissue samples.
The total cost depends on certain factors like equipment used, clinical labor, supplies, and indirect expenses. Factors like the condition of the patient, the severity of the symptoms, and the complexity of the procedure also influence the total cost.
The procedure usually takes 15 to 30 minutes. This is the procedure duration, while pre-procedure and post-procedure protocols take longer.