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General Surgery Coding Alert

You Be the Coder:
Second Dilation Yields Reduced Pay

Question: Our surgeon performed an EGD with balloon dilation, followed by a separate EGD with biopsy. Is it correct to submit the claim as 43249 and 43239-59, listing 43249 first because the RVUs are 5.23, as opposed to 5.15 for 43239? Texas Subscriber Answer: You're correct in your code selection, but you should not report the codes with modifier 59 (Distinct procedural service). You should bill 43239 first because it contains higher RVUs (10.33) and then 43249 as it contains (5.19) RVUs. Here's why: Medicare's Correct Coding Initiative (CCI) doesn't bundle the following codes: 43239 -- Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple 43249 -- Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with balloon dilation of esophagus )less than 30 mm diameter). Your claims processing software should recognize these codes as being from the [...]


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