Physicians face numerous challenges in medical billing. They are unaware of the facts and information required to bill various CPT codes. For instance, they are often confused about the required modifiers. Do each payer have the same billing policies, and what information should be included in the documents?
We totally get this frustration! For this reason, we have decided to address each CPT code and create detailed guides. Today, we will learn about an important gastrointestinal (GI) code, CPT code 43235. In this blog, we will try to answer all of your questions. So let’s find out!
CPT Code 43235 – Description
CPT code 43235 refers to a diagnostic procedure called esophagogastroduodenoscopy (EGD) using an endoscope.
But what exactly happens during the procedure? It is a minimally invasive procedure in which a gastroenterologist inserts a long, thin tube with a light and camera through the patient’s mouth to the esophagus, stomach, and duodenum to examine the upper GI tract. This diagnostic procedure helps to identify gastrointestinal diseases or disorders and collect tissue samples (through brushing or washing).
Appropriate Use Cases for CPT Code 43235
Esophagogastroduodenoscopy is used to diagnose various gastrointestinal issues. The following are some of the common uses of code 43235.
Dysphagia
Think of a scenario where a 62-year-old patient comes to a physician to report that he notices pain while swallowing and feels the food is stuck in the chest while eating. The physician suspects narrowing of the esophagus due to dysphagia. He conducts an upper endoscopy to inspect the esophagus and stomach for abnormalities.
Since an EGD was performed for diagnostic purposes, the physician may bill his services with CPT code 43235.
Indication of GI Bleeding
A 55-year-old patient visits the emergency room after experiencing weakness, vertigo, and black, tarry stools. The patient has anemia, according to blood tests, and the physician believes there may be bleeding in the upper gastrointestinal system.
To check for ulcers, inflammation, or other potential sources of bleeding in the stomach or esophagus, an upper endoscopy is carried out. During the process, the physician locates a potential source of bleeding but does not administer injectable therapy, cauterization, or a biopsy. CPT code 43235 is suitable since the examination is solely diagnostic.
Upper Abdominal Pain
For our last example, let’s think of a 50-year-old man who comes with a complaint of constant pain in the upper abdomen for more than three months. The patient further adds that this discomfort increases after eating and leads to nausea sometimes. The physician believes the patient may have upper gastrointestinal tract inflammation or gastritis. So he performs an upper GI endoscopy to obtain a better view of the stomach, esophagus, and the upper small intestine.
This service must be reported with CPT code 43235 because the procedure was performed for visual inspection of the stomach.
Modifiers to Append with CPT Code 43235
The following are some applicable modifiers for CPT 43235.
Modifier 22
Modifier 22 refers to increased procedural services. This can be appended to CPT code 43235 if the EGD procedure required significantly more effort, intensity, and time than usual.
Modifier 52
Modifier 52 is the opposite of modifier 22; it indicates reduced services. You must append this modifier to CPT code 43235 if a physician performs a less extensive EGD, such as only examining the patient’s esophagus, but not his stomach and duodenum.
Modifier 53
Modifier 53 refers to a discontinued service due to complicating conditions threatening the patient’s life. You may apply this modifier to CPT code 43235 if the procedure was discontinued after administering anesthesia.
Reimbursement Guidelines for CPT Code 43235
Here are some essential billing guidelines for CPT code 43235.
Include Essential Documentation
Healthcare providers must keep accurate records if they wish to receive full payment for their services. What should be included in the documentation, though, is the question. The procedure’s strong medical need, which each professional must state, is the most crucial component of the documentation.
Additionally, include additional minor but crucial data exclusively for code 43235, like:
- Visible symptoms (e.g., dysphagia or unexplained GI bleeding)
- Valid reason for the diagnostic procedure
- Procedure’s findings
- Treatment plan or medical decisions based on the findings
- Method of obtaining specimen (brushing or washing)
Follow Payer-Specific Rules
Another vital factor to keep in mind when filing claims for the CPT code 43235 is ensuring compliance with the insurance payers’ rules. If you do not meet the specific payer’s requirements, you will potentially face denials. But you can avoid this by keeping up with each payer’s changing policies and obtaining prior authorizations before performing the procedure and billing for it.
Final Thoughts
Finally, it is time to wrap up our blog. But here is a quick recap.
CPT code 43235 is used to bill an esophagogastroduodenoscopy (EGD) procedure performed to diagnose upper GI tract conditions. Some common examples of this code’s usage are when diagnosing and billing for upper abdominal pain, abnormal bleeding, and dysphagia. However, you must use modifiers when necessary and demonstrate in your documents why the service was increased, decreased, or discontinued.
We believe this comprehensive read has covered most of the essential information required for using CPT code 43235 in your claims. But if your queries still remain unanswered, we suggest that you opt for professional gastroenterology billing services instead of trying to figure out medical billing on your own. It will help you save time and avoid costly denials.
