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CPT 91035 is not being paid by the majority of the insurance companies- Why?

  1. #1
    Default CPT 91035 is not being paid by the majority of the insurance companies- Why?
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    CPT 91035 is not being paid by the majority of the insurance companies. We need to find out how to get this CPT code paid. Do we need to add a modifier, obtain additional prior auths? This is usually billed with CPT 43235. Even when its billed by itself it is being denied. Anyone knows what happen here?

  2. #2
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    Usually its the other way around 91035 is inclusive in 43235. See the NCCI Manual:

    2. The gastroesophageal reflux test described by CPT code 91035 requires attachment of a telemetry pH electrode to the esophageal mucosa. If a physician uses endoscopic guidance to attach the electrode, the physician shall not report CPT code 43235 (esophagogastroduodenoscopy,...; diagnostic...) for the guidance procedure. The guidance is not separately reportable. Additionally it would be a misuse of CPT code 43235 since this code does not describe guidance, but a more extensive diagnostic endoscopy.
    CRC (2018), CPC-P-A (2016), COC-A (2016), CPC-A (2015), PAHM (2010)
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  3. #3
    Default CPT code91035- still confused
    Quote Originally Posted by CodingKing View Post
    Usually its the other way around 91035 is inclusive in 43235. See the NCCI Manual:

    2. The gastroesophageal reflux test described by CPT code 91035 requires attachment of a telemetry pH electrode to the esophageal mucosa. If a physician uses endoscopic guidance to attach the electrode, the physician shall not report CPT code 43235 (esophagogastroduodenoscopy,...; diagnostic...) for the guidance procedure. The guidance is not separately reportable. Additionally it would be a misuse of CPT code 43235 since this code does not describe guidance, but a more extensive diagnostic endoscopy.
    So we are not to bill with 43235 anymore and if stop billing that way it would get paid solo? Do I use a modifier to state that difference in technique utilization?

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