Wiki Discontinued EGD with foreign body removal

[Rachelbr91]

I am having trouble getting Medicare to pay for a 43247 with a 52 modifier. Patient was seen at the hospital by our doctor on call due to food stuck in esophagus. The decision was made to proceed with an EGD. The food in the esophagus was removed and the endoscope reached the stomach. The duodenum was not reached due to food coming back up into the esophagus. Our provider noted the reduced services and the duodenum was not reached. Medicare is not wanting to pay on claims with 53/52 modifiers even after submitting documentation. Should I rebill as a 43215 since this code better describes the procedure or keep trying to fight for Medicare to pay on the 43247 with 52 modifier.

 

[tkermode]

Depends on the extent of the scope, per CPT, "For examination of the esophagus from the cricopharyngeus muscle (upper esophageal sphincter) to and including the gastroesophageal junction, including examination of the proximal region of the stomach via retroflexion when performed, see [esophagoscopy codes]."

If the provider planned to do a full EGD, entered and examined the stomach, and attempted to pass the pylorus but was unable to, use modifier 53.
If the provider did not plan to examine the duodenum, but entered and examined the entire stomach, use EGD code with modifier 52.
If the provider was unable to examine beyond the stomach proximal to the GEJ, use an esophagoscopy code.

 

[Rachelbr91]

Thank you for the response! I feel like after reviewing procedure that it would fall under 43247 with modifier 53. I will correct and rebill. I just always have so many issues getting payment for any procedure code with 53/52. I always submit documentation and include a claim note indicating reason for the modifier.