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CPT 43256 & 43247 Each x3 Svcs on Same Day

  1. Question CPT 43256 & 43247 Each x3 Svcs on Same Day
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    Good Morning! Please I need assistance, advise or leads to where details of these CPT descriptions can be found.

    The physician performed each of the services up to 3 times per code on same day. Both codes are used on different days, although 43256 x3 one day & 43247 x3 another day. The codes originally paid contracted rate for 1 service & others denied as duplicate. Sent dispute w/documentation to no avail, it was denied again!
    On 4/21/09 Dr performed & billed 43256 -22, unpaid-denied as duplicate, 43256 -59-22 paid contracted rate, & 43256 -59-22 unpaid-denied as duplicate. On 5/5/09, Dr performed & billed necessary procedures, which included 43256 -22, unpaid-denied as duplicate, 43256 -59-22 paid contracted rate, & 43256 -59-22 unpaid-denied as duplicate, exactly as they paid 1st claim. Our pt was critical care/coma on 6/3/09 performed 43247 -22 denied as duplicate charge, 43247 -59 -22 paid contracted rate, 43247 -59 -22 denied as duplicate charge, & 43236 -59 -22 paid contracted fee.

    The descriptions I have do not specify &/or not clear enough to determine if cpts are used for one or multiple placements/removals. My opinion would be that additional time, skill and work was done by the physician. Therefore additional reimbursement is due. Physician performed multiple services w/same cpt code. Again placements &/or removals were in different locations, work, time, technique & skill and Dr. Should Be Reimbursed Additional money for his service. I stated the above & more in the dispute letter.

    Are the codes to be reimbursed for one & the same allowed for multiple procedures? Thanks for any insight, documentation, assistance, &/or solutions to this problem is GREATLY APPRECIATED! So

    Have a wonderful weekend!
    Last edited by TNavarre; 10-01-2009 at 05:00 PM.

  2. #2
    Default
    Here are some descriptions of those procedures in detail if you still need them. Maybe it will help...


    CPT Lay Descriptions
    10021 - 19396 30000 - 39561 50010 - 59871 70010 - 79445 90281 - 99607
    20000 - 29907 40490 - 49906 60000 - 69990 80047 - 89356 0016T - 0198T


    43256

    The physician uses an endoscope to examine the upper gastrointestinal tract and performs a transendoscopic stent placement. The physician passes an endoscope through the patient's mouth into the esophagus. The esophagus, stomach, duodenum, and sometimes the jejunum are viewed. The endoscope is placed at the site of an obstruction or stricture, the necessary stent length is determined and predilation of the obstruction or stenosis may be performed. The stent (endoprosthesis) is introduced into the site of the obstruction. Using a commercial delivery system a plastic covering over the stent is removed and the stent self-deploys, shoring-up the walls at a specific site in the esophagus or proximal small intestine. When necessary, a balloon catheter is placed into the stent and gently inflated to more fully deploy the stent. The delivery system and endoscope are removed.

    CPT Lay Descriptions
    10021 - 19396 30000 - 39561 50010 - 59871 70010 - 79445 90281 - 99607
    20000 - 29907 40490 - 49906 60000 - 69990 80047 - 89356 0016T - 0198T


    43247

    The physician uses an endoscope to examine the upper gastrointestinal tract to locate and remove a foreign body. The physician passes an endoscope through the patient's mouth into the esophagus. The esophagus, stomach, duodenum and sometimes the jejunum are viewed. The foreign body is located. It may be suctioned, or grasped with forceps and retracted through the endoscope.

  3. Question 43256 & 43247 Descriptions
    Hi! Thank you Leslie for the Descriptions for the CPT's! I really appreaciate any & all information shared &/or provided!

    I have read & reread the descriptions multiple times, as well as other explanations & still don't seem to be able to determine if multiple stents/more than 1 stent is placed, is the code 43256 billed w/1 unit? Should a modifier be added for additional stents placed, separately: areas, type & work, all significant, different & necessary. The stent placements originally started with three various stents, then 2 to 3, with removals of all or some stents.

    In a previous related posting, I typed most of the Dr's dictated note(s) for a few of these placements/removals. This was an unfortunate case the Dr was called in on after ICU hospital admission w/multiple problems & previous events. Originally stemming from gastric bypass & different attempts to make stomach smaller for weight loss. Patient had several serious issues, breathing, went into a coma for a period & so on. This particular hospitalization was for more than a month & she is much better today.

    Anyway, I need to be able to interprete the units by the description(s) of these codes? Do you use an alternative code(s)? What or how are other coders billing multiple of the above services? What is your understanding of these code(s)? How many units per code(s)? Does it apply to one placement &/or 1 removal per session? If multiple stents are placed &/or removed during same session, should it be identified by # of units on claim? Or like it was originally billed? Are these codes correct for any nprocedure performed; the placements/removals of multiple stents? What different code(s), should be used?

    Sincerely, I do appreciate your help! Please I am sure this simple problem, I have made complexed & it is driving me.... I want to appeal w/correct info. Please any help, advise, anything is appreciated! Thank You All!
    Last edited by TNavarre; 10-08-2009 at 11:20 AM.

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