General Surgery Coding Alert

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 same family and should reduce payment accordingly. If the multiple endoscopies belong to the same group and are not bundled under CCI, then you can expect payment for the highest paying procedure at 100 percent. You'll receive payment for the other endoscopy at a reduced rate that deducts the value of the group's base code.

Some commercial payers bundle these codes, so you should find and follow their guidance, which may include modifier use to indicate that the 43239 biopsy occurred during a separate dilation.