In CPT 43235, the provider inserts a scope into the mouth which is passed through the pylorus into the duodenum. The provider then inspects the structures and, if necessary, collects some specimens for microscopic analysis by simply brushing or washing the area with a saline solution. After completion of the procedure, the scope is withdrawn.
Whereas, in CPT 43248, the provider inserts a scope into the mouth and down the throat into the esophagus, stomach, and duodenum. The provider then inspects the upper GI tract. He then inserts a guidewire through the scope and removes the scope. The provider then inserts one or more dilators over the guidewire (e.g., Savary–Gillard).
On the other hand, in CPT 43450, the provider passes a bougie or sound into the esophagus. This may be repeated several times, gradually increasing the diameter of the instrument each time until the provider believes that he has achieved sufficient or maximum dilation of the esophagus. The provider may use a lighted endoscope before and after the dilations to examine the stricture and check for any potential injury but performs the dilations without the aid of an endoscope. At the end of the procedure, the provider removes all instruments.
When dilation has been performed with the Savory dilator, then CPT 43248 is appropriate to bill for EGD with Savory dilator, as it is mentioned in the code lay description itself, i.e. provider then inserts one or more dilators over the guidewire e.g., "Savary–Gillard".
If your provider still had performed the dilation separately, then billing 43235 and 43450 showing no bundling, whereas 43248 and 43450 can be billed with modifier 59 with 43450. Since, CPT 43450 covers the dilation, then billing CPT 43450 with it might land-up with denial.
Also, if you are billing only 43248 procedure codes and think that provider had performed extra work during the procedure, then append modifier 22 (Increased Procedural Services) with CPT 43248.
In order to append modifier 22 to a surgical procedure, check that the physician documented the reason(s) why the work he performed was more than he typically performs, and the documentation should include any or all of the following:
- Increased intensity
- Additional time
- Technical difficulty
- Severe patient condition, which causes the surgery to be difficult, dangerous to the patient, and requires additional physical and mental effort from the physician
An unusual procedure is not when the physician took only a few extra minutes on the patient’s case or when the physician documents that the procedure was only slightly more difficult. There is an average range of difficulty for every procedure. A procedure could be slightly more difficult and still meet the definition of the procedure and not warrant appending modifier 22.
Hope this helps!