43261
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
6.00
Facility
$295.60
Non-Facility
$295.60
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.
- All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.
- Every page of the record must be legible and include appropriate patient identification information, including complete patient name and dates of service.
Key Coverage Criteria
- Upper gastrointestinal endoscopy (diagnostic or therapeutic) is covered when determined reasonable and necessary per Local Coverage Determination L35350.
- 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.
- EGD is indicated for persistent or recurrent gastroesophageal reflux disease (GERD) symptoms despite appropriate medical therapy.
4 Active Policies
A57414 — Billing and Coding: Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
J12
L35350 — Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
J12
A56389 — Billing and Coding: Upper Gastrointestinal Endoscopy and Visualization
L34434 — Upper Gastrointestinal Endoscopy and Visualization
Related Codes
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