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43250
Quick jump to procedure code: Printer Friendly Version
43252

CPT® 43251: ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE

Short Description: Egd remove lesion snare

--

CPT copyright 2015 American Medical Association. All rights reserved.


Medicare Reimbursement Information         Hide this section.

ALABAMA-Entire State
ALASKA-Entire State
ARIZONA-Entire State
ARKANSAS-Entire State
CALIFORNIA NORTH-Marin/Napa/Solano
CALIFORNIA NORTH-San Francisco
CALIFORNIA NORTH-San Mateo
CALIFORNIA NORTH-Oakland/Berkeley
CALIFORNIA NORTH-Santa Clara
CALIFORNIA NORTH-Rest of North California
CALIFORNIA SOUTH-Ventura
CALIFORNIA SOUTH-Los Angeles
CALIFORNIA SOUTH-Anaheim/Santa Ana
CALIFORNIA SOUTH-Rest of South California
COLORADO-Entire State
CONNECTICUT-Entire State
DELAWARE-Entire State
DIST of COL-DC + MD/VA Suburbs
FLORIDA-Ft Lauderdale
FLORIDA-Miami
FLORIDA-Rest of Florida
GEORGIA-Atlanta
GEORGIA-Rest of Georgia
HAWAII/GUAM-Entire State/Terr.
IDAHO-Entire State
ILLINOIS-East St. Louis
ILLINOIS-Suburban Chicago
ILLINOIS-Chicago
ILLINOIS-Rest of Illinois
INDIANA-Entire State
IOWA-Entire State
KANSAS-Entire State
KENTUCKY-Entire State
LOUISIANA-New Orleans
LOUISIANA-Rest of Louisiana
MAINE-Southern Maine
MAINE-Rest of Maine
MARYLAND-Baltimore and suburbs
MARYLAND-Rest of Maryland
MASSACHUSETTS-Boston
MASSACHUSETTS-Rest of Massachusetts
MICHIGAN-Detroit
MICHIGAN-Rest of Michigan
MINNESOTA-Entire State
MISSISSIPPI-Entire State
MISSOURI-Kansas City
MISSOURI-St. Louis
MISSOURI-Rest of Missouri
MONTANA-Entire State
NEBRASKA-Entire State
NEVADA-Entire State
NEW HAMPSHIRE-Entire State
NEW JERSEY-Northern NJ
NEW JERSEY-Rest of New Jersey
NEW MEXICO-Entire State
NEW YORK-Manhattan
NEW YORK-NYC Suburbs/LI
NEW YORK-Poughkpsie/No NYC Sub
NEW YORK-Rest of New York
NEW YORK-Queens
NORTH CAROLINA-Entire State
NORTH DAKOTA-Entire State
OHIO-Entire State
OKLAHOMA-Entire State
OREGON-Portland
OREGON-Rest of Oregon
PENNSYLVANIA-Philadelphia
PENNSYLVANIA-Rest of Pennsylvania
PUERTO RICO-Entire Territory
RHODE ISLAND-Entire State
SOUTH CAROLINA-Entire State
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TEXAS-Brazoria
TEXAS-Dallas
TEXAS-Galveston
TEXAS-Houston
TEXAS-Beaumont
TEXAS-Fort Worth
TEXAS-Austin
TEXAS-Rest of Texas
UTAH-Entire State
VERMONT-Entire State
VIRGIN ISLANDS-Entire State
VIRGINIA-Entire State
WASHINGTON-Seattle (King County)
WASHINGTON-Rest of Washington
WEST VIRGINIA-Entire State
WISCONSIN-Entire State
WYOMING-Entire State

2016 Physician
Fee Schedule:

Global Non-Facility Fee
Global Facility Fee
$508.40
$212.46

2016 Wage Index Adjustment for Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payments
Zip Code:
2016 JulyUnadjusted OPPS Payment $1088.00
2016 July Unadjusted ASC Payment $608.39


*Based on National 2013 Medicare Part B submitted claims.
2016 APC Code: 5302
Level 2 Upper GI Procedures

2016 OPPS Status Indicator: T

Effective April 1, 2013, and while sequestration is in effect, all CMS payments for services will be reduced by 2%. The fees above do not reflect this reduction. Click here for more information.

Commonly Associated Diagnosis Codes*            Hide this section.
PercentageICD-9ICD-10 Conversions
27.5% 211.1    Benign neoplasm of stomach D13.1   Benign neoplasm of stomach
OR:
K31.7   Polyp of stomach and duodenum
8.1% 553.3    Diaphragmatic hernia K44.9   Diaphragmatic hernia without obstruction or gangrene
5.2% 535.50    Unspecified gastritis and gastroduodenitis without hemorrhage K29.70   Gastritis, unspecified, without bleeding
OR:
K29.90   Gastroduodenitis, unspecified, without bleeding
4.0% 530.85    Barrett's esophagus K22.70   Barrett's esophagus without dysplasia
3.7% 211.2    Benign neoplasm of duodenum, jejunum, and ileum D13.2   Benign neoplasm of duodenum
OR:
D13.30   Benign neoplasm of unspecified part of small intestine
OR:
D13.39   Benign neoplasm of other parts of small intestine
3.3% 530.81    Esophageal reflux K21.9   Gastro-esophageal reflux disease without esophagitis
3.1% 535.40    Other specified gastritis without hemorrhage K29.60   Other gastritis without bleeding
2.2% 787.20    Dysphagia, unspecified R13.0   Aphagia
OR:
R13.10   Dysphagia, unspecified
2.0% 530.3    Stricture and stenosis of esophagus K22.2   Esophageal obstruction
1.8% 535.00    Acute gastritis without hemorrhage K29.00   Acute gastritis without bleeding

* Commonly Associated ICD-10 codes derived from 2010 Physician Supplier Part B Medicare claims data and 2015 CMS General Equivalency Mapping Codes (GEM).
This data represents an analysis of 43 million claims processed for 1.7 million beneficiaries in 2010.

Medicare Coverage Policy Information         Hide this section.
No contractor selected.

43251 not found in an Local Coverage Determination (LCD) for your contractor. Other contractors covering 43251

CCI and MUE Edits*         Hide this section.

CCI Edits for 43251
Denied Codes (1)
Effective
Modifier
Accepted (2)
00520 Anesth chest procedure
07/01/2002 No
00740 Anesth upper gi visualize
01/01/1998 No
00810 Anesth low intestine scope
07/01/2002 No
0213T Njx paravert w/us cer/thor
07/01/2010 No
0216T Njx paravert w/us lumb/sac
07/01/2010 No
0228T Njx tfrml eprl w/us cer/thor
10/01/2010 No
0230T Njx tfrml eprl w/us lumb/sac
10/01/2010 No
12001 Rpr s/n/ax/gen/trnk 2.5cm/<
10/01/2012 Yes
12002 Rpr s/n/ax/gen/trnk2.6-7.5cm
10/01/2012 Yes
12004 Rpr s/n/ax/gen/trk7.6-12.5cm
10/01/2012 Yes
12005 Rpr s/n/a/gen/trk12.6-20.0cm
10/01/2012 Yes
12006 Rpr s/n/a/gen/trk20.1-30.0cm
10/01/2012 Yes
12007 Rpr s/n/ax/gen/trnk >30.0 cm
10/01/2012 Yes
12011 Rpr f/e/e/n/l/m 2.5 cm/<
10/01/2012 Yes
12013 Rpr f/e/e/n/l/m 2.6-5.0 cm
10/01/2012 Yes
12014 Rpr f/e/e/n/l/m 5.1-7.5 cm
10/01/2012 Yes
12015 Rpr f/e/e/n/l/m 7.6-12.5 cm
10/01/2012 Yes
12016 Rpr fe/e/en/l/m 12.6-20.0 cm
10/01/2012 Yes
12017 Rpr fe/e/en/l/m 20.1-30.0 cm
10/01/2012 Yes
12018 Rpr f/e/e/n/l/m >30.0 cm
10/01/2012 Yes
12020 Closure of split wound
10/01/2012 Yes
12021 Closure of split wound
10/01/2012 Yes
12031 Intmd rpr s/a/t/ext 2.5 cm/<
10/01/2012 Yes
12032 Intmd rpr s/a/t/ext 2.6-7.5
10/01/2012 Yes
12034 Intmd rpr s/tr/ext 7.6-12.5
10/01/2012 Yes
12035 Intmd rpr s/a/t/ext 12.6-20
10/01/2012 Yes
12036 Intmd rpr s/a/t/ext 20.1-30
10/01/2012 Yes
12037 Intmd rpr s/tr/ext >30.0 cm
10/01/2012 Yes
12041 Intmd rpr n-hf/genit 2.5cm/<
10/01/2012 Yes
12042 Intmd rpr n-hf/genit2.6-7.5
10/01/2012 Yes
12044 Intmd rpr n-hf/genit7.6-12.5
10/01/2012 Yes
12045 Intmd rpr n-hf/genit12.6-20
10/01/2012 Yes
12046 Intmd rpr n-hf/genit20.1-30
10/01/2012 Yes
12047 Intmd rpr n-hf/genit >30.0cm
10/01/2012 Yes
12051 Intmd rpr face/mm 2.5 cm/<
10/01/2012 Yes
12052 Intmd rpr face/mm 2.6-5.0 cm
10/01/2012 Yes
12053 Intmd rpr face/mm 5.1-7.5 cm
10/01/2012 Yes
12054 Intmd rpr face/mm 7.6-12.5cm
10/01/2012 Yes
12055 Intmd rpr face/mm 12.6-20 cm
10/01/2012 Yes
12056 Intmd rpr face/mm 20.1-30.0
10/01/2012 Yes
12057 Intmd rpr face/mm >30.0 cm
10/01/2012 Yes
13100 Cmplx rpr trunk 1.1-2.5 cm
10/01/2012 Yes
13101 Cmplx rpr trunk 2.6-7.5 cm
10/01/2012 Yes
13102 Cmplx rpr trunk addl 5cm/<
10/01/2012 Yes
13120 Cmplx rpr s/a/l 1.1-2.5 cm
10/01/2012 Yes
13121 Cmplx rpr s/a/l 2.6-7.5 cm
10/01/2012 Yes
13122 Cmplx rpr s/a/l addl 5 cm/>
10/01/2012 Yes
13131 Cmplx rpr f/c/c/m/n/ax/g/h/f
10/01/2012 Yes
13132 Cmplx rpr f/c/c/m/n/ax/g/h/f
10/01/2012 Yes
13133 Cmplx rpr f/c/c/m/n/ax/g/h/f
10/01/2012 Yes
13151 Cmplx rpr e/n/e/l 1.1-2.5 cm
10/01/2012 Yes
13152 Cmplx rpr e/n/e/l 2.6-7.5 cm
10/01/2012 Yes
13153 Cmplx rpr e/n/e/l addl 5cm/<
10/01/2012 Yes
31505 Diagnostic laryngoscopy
07/01/2003 No
31525 Dx laryngoscopy excl nb
07/01/2003 No
31575 Diagnostic laryngoscopy
07/01/2003 No
36000 Place needle in vein
01/01/1996 Yes
36005 Injection ext venography
01/01/1996 Yes
36010 Place catheter in vein
01/01/1996 Yes
36011 Place catheter in vein
01/01/1996 Yes
36012 Place catheter in vein
01/01/1996 Yes
36013 Place catheter in artery
01/01/1996 Yes
36014 Place catheter in artery
01/01/1996 Yes
36015 Place catheter in artery
01/01/1996 Yes
36400 Bl draw < 3 yrs fem/jugular
04/01/2009 Yes
36405 Bl draw <3 yrs scalp vein
04/01/2009 Yes
36406 Bl draw <3 yrs other vein
04/01/2009 Yes
36410 Non-routine bl draw 3/> yrs
01/01/1998 Yes
36420 Vein access cutdown < 1 yr
04/01/2009 Yes
36425 Vein access cutdown > 1 yr
04/01/2009 Yes
36430 Blood transfusion service
04/01/2009 Yes
36440 Bl push transfuse 2 yr/<
04/01/2009 Yes
36591 Draw blood off venous device
10/01/2015 No
36592 Collect blood from picc
10/01/2015 No
36600 Withdrawal of arterial blood
04/01/2009 Yes
36640 Insertion catheter artery
04/01/2009 Yes
43180 Esophagoscopy rigid trnso
01/01/2015 No
43191 Esophagoscopy rigid trnso dx
04/01/2014 No
43192 Esophagoscp rig trnso inject
04/01/2014 No
43193 Esophagoscp rig trnso biopsy
04/01/2014 No
43194 Esophagoscp rig trnso rem fb
04/01/2014 No
43195 Esophagoscopy rigid balloon
04/01/2014 No
43196 Esophagoscp guide wire dilat
04/01/2014 No
43197 Esophagoscopy flex dx brush
04/01/2014 No
43198 Esophagosc flex trnsn biopsy
04/01/2014 No
43200 Esophagoscopy flexible brush
01/01/1997 No
43201 Esoph scope w/submucous inj
01/01/2003 No
43202 Esophagoscopy flex biopsy
01/01/2002 No
43204 Esoph scope w/sclerosis inj
01/01/2002 No
43205 Esophagus endoscopy/ligation
01/01/2002 No
43206 Esoph optical endomicroscopy
01/01/2013 No
43210 Egd esophagogastrc fndoplsty
01/01/2016 No
43211 Esophagoscop mucosal resect
01/01/2014 No
43212 Esophagoscop stent placement
01/01/2014 No
43213 Esophagoscopy retro balloon
01/01/2014 No
43214 Esophagosc dilate balloon 30
01/01/2014 No
43215 Esophagoscopy flex remove fb
01/01/2002 No
43216 Esophagoscopy lesion removal
01/01/2002 No
43217 Esophagoscopy snare les remv
01/01/1997 No
43220 Esophagoscopy balloon <30mm
01/01/2002 No
43226 Esoph endoscopy dilation
01/01/2002 No
43227 Esophagoscopy control bleed
01/01/2002 No
43229 Esophagoscopy lesion ablate
01/01/2014 No
43231 Esophagoscop ultrasound exam
01/01/2002 No
43232 Esophagoscopy w/us needle bx
01/01/2002 No
43235 Egd diagnostic brush wash
01/01/1997 No
43239 Egd biopsy single/multiple
04/01/2002 Yes
43250 Egd cautery tumor polyp
01/01/2004 Yes
43255 Egd control bleeding any
10/01/1996 Yes
43752 Nasal/orogastric w/tube plmt
04/01/2009 Yes
43753 Tx gastro intub w/asp
01/01/2011 Yes
43754 Dx gastr intub w/asp spec
01/01/2011 No
43756 Dx duod intub w/asp spec
07/01/2012 No
44360 Small bowel endoscopy
01/01/1997 No
44361 Small bowel endoscopy/biopsy
01/01/2015 Yes
44363 Small bowel endoscopy
01/01/2015 Yes
44365 Small bowel endoscopy
01/01/2015 Yes
44373 Small bowel endoscopy
01/01/2015 Yes
44376 Small bowel endoscopy
01/01/1997 No
51701 Insert bladder catheter
10/01/2007 Yes
51702 Insert temp bladder cath
10/01/2007 Yes
51703 Insert bladder cath complex
10/01/2007 Yes
62310 Inject spine cerv/thoracic
04/01/2009 No
62311 Inject spine lumbar/sacral
04/01/2009 No
62318 Inject spine w/cath crv/thrc
10/01/2002 No
62319 Inject spine w/cath lmb/scrl
10/01/2002 No
64400 N block inj trigeminal
04/01/2009 No
64402 N block inj facial
04/01/2009 No
64405 N block inj occipital
04/01/2009 No
64408 N block inj vagus
04/01/2009 No
64410 N block inj phrenic
04/01/2009 No
64413 N block inj cervical plexus
04/01/2009 No
64415 N block inj brachial plexus
10/01/2002 No
64416 N block cont infuse b plex
01/01/2003 No
64417 N block inj axillary
10/01/2002 No
64418 N block inj suprascapular
04/01/2009 No
64420 N block inj intercost sng
04/01/2009 No
64421 N block inj intercost mlt
04/01/2009 No
64425 N block inj ilio-ing/hypogi
04/01/2009 No
64430 N block inj pudendal
04/01/2009 No
64435 N block inj paracervical
04/01/2009 No
64445 N block inj sciatic sng
04/01/2009 No
64446 N blk inj sciatic cont inf
04/01/2009 No
64447 N block inj fem single
04/01/2009 No
64448 N block inj fem cont inf
04/01/2009 No
64449 N block inj lumbar plexus
04/01/2009 No
64450 N block other peripheral
10/01/2002 No
64461 Pvb thoracic single inj site
01/01/2016 No
64463 Pvb thoracic cont infusion
01/01/2016 No
64479 Inj foramen epidural c/t
04/01/2009 No
64483 Inj foramen epidural l/s
04/01/2009 No
64486 Tap block unil by injection
01/01/2015 No
 
Denied Codes (1)
Effective
Modifier
Accepted (2)
64487 Tap block uni by infusion
01/01/2015 No
64488 Tap block bi injection
01/01/2015 No
64489 Tap block bi by infusion
01/01/2015 No
64490 Inj paravert f jnt c/t 1 lev
01/01/2010 No
64493 Inj paravert f jnt l/s 1 lev
01/01/2010 No
64505 N block spenopalatine gangl
04/01/2009 No
64508 N block carotid sinus s/p
04/01/2009 No
64510 N block stellate ganglion
04/01/2009 No
64517 N block inj hypogas plxs
04/01/2009 No
64520 N block lumbar/thoracic
04/01/2009 No
64530 N block inj celiac pelus
04/01/2009 No
69990 Microsurgery add-on
06/05/2000 No
76000 Fluoroscope examination
10/01/2009 Yes
76001 Fluoroscope exam extensive
10/01/2009 Yes
77001 Fluoroguide for vein device
01/01/2011 Yes
77002 Needle localization by xray
01/01/2011 Yes
92012 Eye exam establish patient
04/01/2014 Yes
92014 Eye exam&tx estab pt 1/>vst
04/01/2014 Yes
92511 Nasopharyngoscopy
07/01/2003 No
93000 Electrocardiogram complete
07/01/2008 Yes
93005 Electrocardiogram tracing
07/01/2008 Yes
93010 Electrocardiogram report
07/01/2008 Yes
93040 Rhythm ecg with report
07/01/2008 Yes
93041 Rhythm ecg tracing
07/01/2008 Yes
93042 Rhythm ecg report
07/01/2008 Yes
93318 Echo transesophageal intraop
04/01/2009 Yes
93355 Echo transesophageal (tee)
01/01/2015 Yes
94002 Vent mgmt inpat init day
04/01/2009 Yes
94200 Lung function test (mbc/mvv)
04/01/2009 Yes
94250 Expired gas collection
04/01/2009 Yes
94680 Exhaled air analysis o2
04/01/2009 Yes
94681 Exhaled air analysis o2/co2
04/01/2009 Yes
94690 Exhaled air analysis
04/01/2009 Yes
94760 Measure blood oxygen level
01/01/1996 No
94761 Measure blood oxygen level
01/01/1996 No
94770 Exhaled carbon dioxide test
07/01/2008 Yes
95812 Eeg 41-60 minutes
04/01/2009 Yes
95813 Eeg over 1 hour
04/01/2009 Yes
95816 Eeg awake and drowsy
04/01/2009 Yes
95819 Eeg awake and asleep
04/01/2009 Yes
95822 Eeg coma or sleep only
04/01/2009 Yes
95829 Surgery electrocorticogram
04/01/2009 Yes
95955 Eeg during surgery
04/01/2009 Yes
96360 Hydration iv infusion init
01/01/2009 Yes
96361 Hydrate iv infusion add-on
04/01/2016 Yes
96365 Ther/proph/diag iv inf init
01/01/2009 Yes
96366 Ther/proph/diag iv inf addon
04/01/2016 Yes
96367 Tx/proph/dg addl seq iv inf
04/01/2016 Yes
96368 Ther/diag concurrent inf
04/01/2016 Yes
96372 Ther/proph/diag inj sc/im
01/01/2009 Yes
96374 Ther/proph/diag inj iv push
01/01/2009 Yes
96375 Tx/pro/dx inj new drug addon
01/01/2009 Yes
96376 Tx/pro/dx inj same drug adon
04/01/2009 Yes
99143 Mod sedat phys/qhp <5 yrs
04/01/2006 No
99144 Mod sedat phys/qhp 5yrs/>
04/01/2006 No
99145 Mod sedat phys/qhp ea 15 min
10/01/2009 No
99148 Mod sed diff phys/qhp<5 yrs
10/01/2008 No
99149 Mod sed diff phys/qhp 5/>yrs
10/01/2008 No
99150 Mod sed diff phys/qhp add on
10/01/2009 No
99211 Office/outpatient visit est
07/01/2013 Yes
99212 Office/outpatient visit est
07/01/2013 Yes
99213 Office/outpatient visit est
07/01/2013 Yes
99214 Office/outpatient visit est
07/01/2013 Yes
99215 Office/outpatient visit est
07/01/2013 Yes
99217 Observation care discharge
07/01/2013 Yes
99218 Initial observation care
07/01/2013 Yes
99219 Initial observation care
07/01/2013 Yes
99220 Initial observation care
07/01/2013 Yes
99221 Initial hospital care
07/01/2013 Yes
99222 Initial hospital care
07/01/2013 Yes
99223 Initial hospital care
07/01/2013 Yes
99231 Subsequent hospital care
07/01/2013 Yes
99232 Subsequent hospital care
07/01/2013 Yes
99233 Subsequent hospital care
07/01/2013 Yes
99234 Observ/hosp same date
07/01/2013 Yes
99235 Observ/hosp same date
07/01/2013 Yes
99236 Observ/hosp same date
07/01/2013 Yes
99238 Hospital discharge day
07/01/2013 Yes
99239 Hospital discharge day
07/01/2013 Yes
99241 Office consultation
07/01/2013 Yes
99242 Office consultation
07/01/2013 Yes
99243 Office consultation
07/01/2013 Yes
99244 Office consultation
07/01/2013 Yes
99245 Office consultation
07/01/2013 Yes
99251 Inpatient consultation
07/01/2013 Yes
99252 Inpatient consultation
07/01/2013 Yes
99253 Inpatient consultation
07/01/2013 Yes
99254 Inpatient consultation
07/01/2013 Yes
99255 Inpatient consultation
07/01/2013 Yes
99291 Critical care first hour
07/01/2013 Yes
99292 Critical care addl 30 min
07/01/2013 Yes
99304 Nursing facility care init
07/01/2013 Yes
99305 Nursing facility care init
07/01/2013 Yes
99306 Nursing facility care init
07/01/2013 Yes
99307 Nursing fac care subseq
07/01/2013 Yes
99308 Nursing fac care subseq
07/01/2013 Yes
99309 Nursing fac care subseq
07/01/2013 Yes
99310 Nursing fac care subseq
07/01/2013 Yes
99315 Nursing fac discharge day
07/01/2013 Yes
99316 Nursing fac discharge day
07/01/2013 Yes
99334 Domicil/r-home visit est pat
07/01/2013 Yes
99335 Domicil/r-home visit est pat
07/01/2013 Yes
99336 Domicil/r-home visit est pat
07/01/2013 Yes
99337 Domicil/r-home visit est pat
07/01/2013 Yes
99347 Home visit est patient
07/01/2013 Yes
99348 Home visit est patient
07/01/2013 Yes
99349 Home visit est patient
07/01/2013 Yes
99350 Home visit est patient
07/01/2013 Yes
99374 Home health care supervision
07/01/2013 Yes
99375 Home health care supervision
07/01/2013 Yes
99377 Hospice care supervision
07/01/2013 Yes
99378 Hospice care supervision
07/01/2013 Yes
99446 Interprof phone/online 5-10
01/01/2014 No
99447 Interprof phone/online 11-20
01/01/2014 No
99448 Interprof phone/online 21-30
01/01/2014 No
99449 Interprof phone/online 31/>
01/01/2014 No
99495 Trans care mgmt 14 day disch
01/01/2014 Yes
99496 Trans care mgmt 7 day disch
01/01/2014 Yes
C9742 Laryngoscopy with injection
07/01/2015 No
G0463 Hospital outpt clinic visit
07/01/2014 Yes
G0471 Ven blood coll snf/hha
07/01/2015 Yes
43254 Egd endo mucosal resection
01/01/2014 Yes
43270 Egd lesion ablation
01/01/2014 Yes
43610 Excision of stomach lesion
01/01/1996 Yes
43611 Excision of stomach lesion
04/01/1997 Yes
43620 Removal of stomach
01/01/1996 Yes
43621 Removal of stomach
01/01/1996 Yes
43622 Removal of stomach
01/01/1996 Yes
43631 Removal of stomach partial
01/01/1996 Yes
43632 Removal of stomach partial
01/01/1996 Yes
43633 Removal of stomach partial
01/01/1996 Yes
43634 Removal of stomach partial
01/01/1996 Yes
43640 Vagotomy & pylorus repair
01/01/1996 Yes
43641 Vagotomy & pylorus repair
01/01/1996 Yes
43800 Reconstruction of pylorus
01/01/1996 Yes
43810 Fusion of stomach and bowel
01/01/1996 Yes
43820 Fusion of stomach and bowel
01/01/1996 Yes
43825 Fusion of stomach and bowel
01/01/1996 Yes
43846 Gastric bypass for obesity
01/01/1996 Yes
43847 Gastric bypass incl small i
04/01/1997 Yes
43850 Revise stomach-bowel fusion
01/01/1996 Yes
43855 Revise stomach-bowel fusion
01/01/1996 Yes
43865 Revise stomach-bowel fusion
01/01/1996 Yes
44364 Small bowel endoscopy
01/01/1999 Yes
44366 Small bowel endoscopy
01/01/2015 Yes
44369 Small bowel endoscopy
01/01/2015 Yes
44370 Small bowel endoscopy/stent
01/01/2015 Yes
44372 Small bowel endoscopy
01/01/2015 Yes
44377 Small bowel endoscopy/biopsy
01/01/2015 Yes
44378 Small bowel endoscopy
01/01/2015 Yes
44379 S bowel endoscope w/stent
01/01/2015 Yes
96570 Photodynmc tx 30 min add-on
06/05/2000 Yes
(1) These codes will be denied when submitted for payment on the same date of service as 43251.

(2) "Yes" indicates that the use of a modifier with the denied code will overcome the edit and allow payment.
"No" indicates that the second code will always be denied.


Medically Unlikely Edits for 43251


Practitioner
Hospital Outpatient
DME Supplier
Allowed Frequency per Day: 1 1 Not Listed
Adjudication Indicator: 2 Date of Service Edit: Policy 2 Date of Service Edit: Policy Not Listed
Rationale: Anatomic Consideration Anatomic Consideration Not Listed

* The responsibility for the content of any "National Correct Coding Policy" included in this product is with the Centers for Medicare and Medicaid Services and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, nonuse, or interpretation of information contained in this product.


   43251 Top 5 Ordering Providers National*
DANIEL MEGNA -STATEN ISLAND,NY 265
MARK NAGRANI -NEW SMYRNA BEACH,FL 192
ARNOLD MERIN -TUCSON,AZ 158
VISHAL GUPTA -ORANGE CITY,FL 123
MANOJ MITTAL -EASTON,PA 103

   43251 Top 5 Ordering Organizations National*
NEW SMYRNA BEACH AMBULATORY CARE CENTER INC-FL 195
BAYSIDE ENDOSCOPY, LLC-RI 132
SOUTHEAST VALLEY ENDOSCOPY CENTER,LLC-AZ 131
NORTHAMPTON ENDOSCOPY CENTER LLC-PA 130
ORANGE CITY SURGERY CENTER LLC-FL 124

*Based on 2014 Medicare Fee-For Service Provider Utilization & Payment Data, Physician and Other Supplier, Public Use File



   Medicare Part B Utilization Data for 43251*         Hide this section.


Annual Procedures / Tests Performed / Denied


Total National Services (all modifiers) Submitted 2015: 40,625
Total Services Denied 2015: 2,113 (5.2%)
National Charges Submitted 2015: $ 47,708,072.00
National Charges Allowed 2015: $ 11,089,999.00
National Average (No Modifier) Fee Submitted 2015: $1281.76
National Average (No Modifier) Fee Allowed 2015: $338.52


Top 5 Performing Specialties 2015 Total Tests Percent
of Total
Average
Amount
Submitted
Denials Percent
Denied
Gastroenterology 26,036 64.1% $853.51 1,305 5.0%
Ambulatory surgical center
(formerly miscellaneous)
10,226 25.2% $2118.02 546 5.3%
General surgery 2,076 5.1% $834.46 86 4.1%
Internal medicine 1,877 4.6% $901.00 140 7.5%
Family practice 147 0.4% $965.30 14 9.5%

Top 5 Places of Service 2015 Total Tests Percent
of Total
Average
Amount
Submitted
Denials Percent
Denied
Ambulatory surgical center 20,865 51.4% $1461.46 1,032 4.9%
Outpatient hospital 15,112 37.2% $852.74 779 5.2%
Inpatient hospital 3,354 8.3% $853.36 214 6.4%
Office 1,266 3.1% $1137.05 83 6.6%
Emergency room - hospital 10 0.0% $740.48 0 0.0%

Top 5 Modifiers Submitted 2015 Total Tests Percent
of Total
Average
Amount
Submitted
Denials Percent
Denied
No Modifier 27,017 66.5% $1281.76 1,445 5.3%
51 - Multiple Procedures 7,264 17.9% $855.64 194 2.7%
59 - Distinct Procedural Service 3,564 8.8% $994.36 309 8.7%
SG 1,123 2.8% $1416.31 57 5.1%
GC 469 1.2% $1064.60 16 3.4%

Click here for more information on Custom CodeMap Medicare Utililation Reports.


*Utilization data is derived from analysis of the Physician Supplier Procedure Summary Master File (PSPSMF) which includes data from all Medicare Part B carriers. This data represents procedure-specific billing data for all physician/supplier services rendered to all Medicare beneficiaries during the calendar year named and processed by the Carriers through the six months of the following year.

Part B charge and utilization data for institutional services (hospital outpatient departments, home health agencies, comprehensive outpatient rehabilitation facilities, end-stage renal disease facilities, and rural health clinics) are processed by Medicare Part A fiscal intermediaries and are not included in this data. Data for services rendered to beneficiaries enrolled in risk-based Health Maintenance Organizations (HMOs) are also not included.

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09/29/2016 01:40:24 54.145.55.135

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