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CPT codes for correct coding initiative

Thomas Posted Wed 21st of January, 2015 16:36:58 PM

Filed a insurance claim with Medicare for an inpatient the physician saw and Medicare payment was made as follows:
99223-25 - Paid
43255 - Denied as procedure under correct coding initiate guidelines
43239-59 - Paid
My understanding was Medicare would cover/process claim CPT's in order they are listed on HCFA claim. Why did they cover the 43239-59 and deny the 43255. Should the CPT codes have been filed in a different order.
Thank you - Oklahoma Subscriber

SuperCoder Answered Wed 21st of January, 2015 17:16:22 PM

Thanks for your question. The 59 modifier for distinct procedural service should have been appended to 43255; Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method. This is why you received the denial from Medicare. Keep in mind that when bleeding occurs as a result of an endoscopic procedure, control of bleeding is not reported separately during the same operative session. So if your physician caused the bleeding when completing the biopsy, the bleeding is not separately reportable. Medicare will normally switch the order of the claim when processing according to RVUs but this will not affect whether they deny or make payment on a claim. Hope this helps.

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