漫香阁

Question: I have a procedure report for an esophagogastroduodenoscopy (EGD). The gastroenterologist performed the EGD and identified achalasia. They used 25 mm balloon dilation and injected 100 units of Botox.

Can I report 43249 and 43236-59 if it鈥檚 the same site?

Wisconsin Subscriber

Answer: No, you cannot report 43249 (Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter)) and 43236 (Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance) appended with modifier 59 (Distinct procedural service) for this encounter.

The National Correct Coding Initiative (NCCI) lists 43236 as a column 2 code for 43249, which means the injection is bundled into the EGD procedure. Code 43236 does carry a modifier indicator of 鈥�1,鈥� so you may unbundle the services with an appropriate modifier if the circumstances call for the unbundling.

According to the CPT^庐 guidelines for modifier 59, the documentation 鈥渕ust support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.鈥�

Therefore, based on the information you鈥檝e provided, the Botox injection occurred at the same site, so you can only report 43249 for the gastroenterologist鈥檚 procedures.

Mike Shaughnessy, BA, CPC, Development Editor, 漫香阁