Does 43210 require prior authorization?

No, 43210 does not require prior authorization (low confidence). No active coverage policies found for this code.

What is the Medicare reimbursement rate for 43210?

Medicare facility rate: $379.43. Non-facility rate: $379.43. Work RVU: 7.56.

HCPCS/CPT

No Prior Auth Required

No active coverage policies found for this code (low confidence)

Work RVU

7.56

Facility

$379.43

Non-Facility

$379.43

This billing and coding guidance complements Local Coverage Determination L34434; follow LCD L34434 for clinical coverage criteria and required documentation for claims.
All services billed with unlisted procedure codes must include sufficient medical records and supporting documentation to allow development and medical review.
The patient's medical record must contain documentation that fully supports medical necessity per LCD L34659, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
Documentation supporting the service must be available to the Contractor upon request.

Coverage is appropriate for Transoral Incisionless Fundoplication (TIF), e.g., EsophyX™, when documentation supports the specific indications listed in LCD L34659.
Services for select minimally invasive GERD procedures are covered when medical necessity is met as defined in the associated Local Coverage Determination (LCD) for Select Minimally Invasive GERD Procedures.
EGD is indicated for management of achalasia with endoscopic techniques (e.g., botulinum toxin injection, balloon dilation).
Diagnostic EGD is indicated for persistent upper abdominal distress despite an appropriate trial of therapy.
Diagnostic EGD is indicated for upper abdominal distress with signs suggesting serious organic disease such as anorexia and weight loss.
EGD is indicated for dysphagia or odynophagia to evaluate esophageal pathology.

A56395 — Billing and Coding: Endoscopic Treatment of GERD

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L34659 — Endoscopic Treatment of GERD

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L35080 — Select Minimally Invasive GERD Procedures

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A56863 — Billing and Coding: Select Minimally Invasive GERD Procedures

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Ask Verity about documentation requirements, denial risks, or coverage in your state.