43284
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
9.88
Facility
$626.60
Non-Facility
$626.60
Documentation Required
- The patient's medical record must contain documentation that fully supports medical necessity for services included within the LCD, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
- The article provides billing, coding, or other guidelines that complement LCD L39780 and should be used with that LCD when preparing claims.
- Report of ambulatory pH testing documenting acid exposure time (AET) > 6% must be included in the medical record.
Key Coverage Criteria
- 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.
- Coverage indications follow the Local Coverage Determination (LCD) L39780; this article provides billing and coding guidelines that complement that LCD.
- Transoral incisionless fundoplication (TIF) using the EsophyX device for treatment of gastroesophageal reflux disease (GERD) is covered to reconstruct the gastroesophageal valve and reduce acid reflux.
- TIF is covered when any hiatal hernia is 2 cm or less, including cases where a prior successful laparoscopic hernia reduction has reduced a hernia to 2 cm or less before TIF.
- Documented GERD based on abnormal ambulatory pH testing with acid exposure time (AET) > 6%.
- Completed appropriate upper endoscopic evaluation and esophageal manometry to exclude other (extra-gastroesophageal) causes of symptoms.
19 Active Policies
A56863 — Billing and Coding: Select Minimally Invasive GERD Procedures
J06
L35080 — Select Minimally Invasive GERD Procedures
J06
PALMETTO-L39780 — Lower Esophageal Magnetic Sphincter Augmentation
JJ Part B
NGS-L35080 — Select Minimally Invasive GERD Procedures
JK MAC Part B
Related Codes
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