CPT Code 43239: Guidelines, Considerations, and Requirements

Are you getting denials over the CPT code 43239? Read this blog to find out exactly what you’re doing wrong. We have covered a lot of details about this code, including modifiers, key guidelines, and billing considerations.

You can also check out the documentation requirements that you must fulfill while assigning it.

What Is CPT Code 43239?

The CPT code 43239 is assigned to esophagogastroduodenoscopy (EGD). It is a diagnostic endoscopic procedure conducted alongside a biopsy. This code is appropriate whenever healthcare providers have to take one or more tissue samples.

These samples have to be taken from the esophagus, stomach, or duodenum. All such samples are taken during the EGD procedure. The purpose of conducting a biopsy is to diagnose different conditions. Those conditions largely include inflammation, infection, and cancer.

The full form of CPT in medical coding is Current Procedural Terminology. This name is associated with specific numeric codes that are assigned to medical services. Healthcare providers and insurance companies use CPT codes to identify those services while billing them.

Modifiers Used With CPT Code 43239

Healthcare providers should be aware of the modifiers that can be assigned with the CPT code 43239. We have covered a wide range of such modifiers just for you:

• Modifier 22: You can use this modifier whenever your actual work done to conduct a medical procedure is severely greater than what is usually done.
• Modifier 26: This modifier is used whenever the professional component of a procedure only is being billed. It is typically applicable for procedures in which the technical component is billed separately.
• Modifier 52: This modifier is applicable whenever a physician partially reduces or eliminates a medical procedure.
• Modifier 53: You can use this modifier whenever you have to discontinue a procedure. The reason can be extenuating circumstances or if the patient’s well-being is threatened.
• Modifier 59: Modifier 59 indicates that a medical procedure is independent of the other procedures that were performed that day.
• Modifier 76: A physician or any other healthcare provider can use it if they repeat a procedure subsequent to the original one.
• Modifier 78: This modifier comes into play whenever you conduct a related procedure during the postoperative period of the original one.
• Modifier 79: This modifier has to be used whenever a related procedure is conducted during the postoperative period of the original one by the same physician.
• Modifier 91: Modifier 91 indicates that you have repeated a clinical diagnostic laboratory test on the same day. The purpose of doing this is to obtain multiple test results.
• Modifier 99: A healthcare provider uses it whenever two or more modifiers are necessary, depending on the medical service provided.

Getting CPT Code 43239 Reimbursements From Medicare

Medicare reimburses CPT code 43239 at varying rates, influenced by multiple factors. The Medicare Physician Fee Schedule (MPFS) provides standardized payment rates for services covered under Medicare credentialing, ensuring compliance with federal guidelines.

However, actual reimbursement amounts may vary based on how the Medicare Administrative Contractor (MAC) in your region processes claims. Each MAC has the authority to interpret Medicare policies and establish local coverage determinations (LCDs), which can impact final reimbursement rates.

To ensure accurate payments and compliance with Medicare credentialing requirements, always refer to your regional MAC and the MPFS for precise reimbursement details.

Key Guidelines for Assigning CPT Code 43239

There are some key guidelines that you must follow while assigning the CPT code 43239. Let’s take a look at them in detail:

Device Type

To assign 43239, you must ensure that the device used was a percutaneous LVAD. This means that it should be inserted through the skin. This code does not apply if the insertion was through a surgical incision. It is a less invasive approach that is different from surgically implanted devices.

The design of that device should also help the left ventricle of the heart to pump blood. This use case is common in patients with severe heart failure. In those cases, the left ventricle does not function adequately.

Placement

The placement of the LVAD device is also crucial. It should be inserted into the left ventricle. This ensures that the heart receives full support for its pumping action.

It is also important for the outflow cannula to be positioned in the ascending aorta. It can also be positioned in the pulmonary artery. You must ensure that it is correctly placed to ensure that the CPT code 43239 can be applied.

Procedure

The procedure should involve the percutaneous insertion of the LVAD through the skin and into the heart. Healthcare providers should use imaging techniques like echocardiography or fluoroscopy. It is also important that the LVAD is connected to a power source outside the patient’s body. The device uses this power source to function properly.

Anesthesia and Complications

You should also clearly document the type of anesthesia used during your procedures. The choice of anesthesia can have an impact on the complexity and risk of your procedures. Therefore, it is an important factor in determining 43239 as the accurate code.

Code selection also depends on the documentation of complications arising during or after the procedure. Primary complications include bleeding, infection, and device malfunction. So, you must ensure that there are sufficient records of any complications as well.

Multiple Devices and Other Services

Multiple LVADs are usually inserted during the same procedure. In this case, you should only report the CPT code 43239. By doing this, you can prevent double billing and maintain proper coding practices.

In some cases, other services are performed in conjunction with the LVAD insertion. These services include cardiac catheterization and coronary artery bypass grafting. These services should be reported with their own CPT codes.

Billing Considerations for CPT Code 43239

You must also be aware of certain considerations while billing claims associated with the CPT code 43239. Here is a detailed explanation of the primary ones:

Medical Necessity

The CPT code 43239 should only be assigned if the insertion of a percutaneous LVAD is deemed medically necessary. To do this, you have to accurately document the condition of your patient. The condition could be anything ranging from a severe heart failure to an end-stage heart disease.

Prior Authorization

Prior authorizations are also important for determining the accuracy of this code. Many insurance payers require prior authorizations for procedures before they are performed. You should verify this requirement of insurance plans. This way, you will be able to receive timely reimbursements for your services.

Documentation

You should also maintain detailed documents to generate accurate medical bills. Recording the diagnosis and medical history of your patients should always be your priority. Other records include the reasons for LVAD insertion.

The type and placement of LVAD, along with other aspects of your procedure, should also be documented. Assigning the accurate code also depends on the documentation of any complications or adverse events.

Appeal Process and Electronic Health Records

Healthcare providers must be familiar with the appeal process of relevant insurers as well if their claims are denied. To appeal, they have to document the reasons for it. They should also provide any additional details to support their appeal.

They can also utilize electronic health records. These records can improve their billing process and ensure that they have documented accurate records. By using EHRs, you can also identify potential coding errors and improve your efficiency.

Documentation Requirements for CPT Code 43239

Healthcare providers must also fulfill certain requirements in terms of their documentation. We have listed some of those requirements below:

Procedural Notes

You must ensure that you have the procedural notes required to assign this code. Those notes contain the specifics of the LVAD insertion procedure. Clearly document the date and time when you perform the procedure. This information is vital for maintaining a precise medical record. It is also critical for legal and billing purposes.

Any complications or adverse events that occur during your procedure should also be documented. This information is essential for patient safety, quality improvement, and potential reimbursement adjustments.

Include details of intraoperative monitoring as well. They include vital signs and hemodynamic parameters. This ensures that your patient’s stability helps in assessing the effectiveness of your procedure.

Postoperative Course

The postoperative course focuses on your patient’s recovery. It also includes any immediate or delayed complications. Include information about the hospital stay. It can include details about the length of recovery and days spent in the ICU.

Record any complications or adverse events that occur postoperatively. Such events primarily comprise arrhythmias, device malfunctions, and infections. This is crucial for follow-up care and may affect assigning the CPT code 43239.

Clearly outline your follow-up care plan as well. It should include regular monitoring of the device. Your patients should also be educated on device care. This outline also has to be based on the scheduling of your follow-up appointments.

Device Information

Accurate documentation of the device specifics is also essential for regulatory, safety, and tracking purposes. Record the manufacturer and model number of your LVAD. It should enable you to maintain accurate device tracking. You can also manage any recalls or technical issues.

The serial number of the device should be documented as well. It is crucial for its precise identification in the case of recalls or malfunction investigations. Document the implant date to ensure accurate records for device longevity.

Discharge Summary

Provide a concise overview of your patient’s preoperative condition. Include the final diagnosis to summarize your patient’s condition. List all discharge medications that can include anticoagulants, antibiotics, and heart failure medications. They are essential for managing the patient post-LVAD insertion.

Document follow-up appointments as well to ensure continuity of care. Provide detailed instructions on how the patient or caregiver should care for the LVAD. They include wound care, power source management, and signs of potential complications.

Device Registry

Documenting the LVAD in a device registry is also a requirement. Ensure that your LVAD is registered in a national or manufacturer-specific registry. This is important for patient safety, device tracking, and recall management.

Conclusion

CPT code 43239 must be accurately assigned to ensure proper medical coding and billing. Understanding the appropriate modifiers, reimbursement guidelines, and documentation requirements is essential for maximizing claims approval and compliance.

For expert medical coding and billing services, contact Health Quest Billing at (415) 508-6537 to optimize accuracy and reimbursement.