43210
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
7.56
Facility
$379.43
Non-Facility
$379.43
Documentation Required
- 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.
Key Coverage Criteria
- 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.
16 Active Policies
L34659 — Endoscopic Treatment of GERD
J05
A56395 — Billing and Coding: Endoscopic Treatment of GERD
J05
L35080 — Select Minimally Invasive GERD Procedures
J06
A56863 — Billing and Coding: Select Minimally Invasive GERD Procedures
J06
WPS-L34659
Related Codes
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