74235
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
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.
- Endoscopic plication or suturing devices that have FDA 510(k) clearance require supporting peer-reviewed literature demonstrating efficacy for medically refractory GERD for coverage consideration.
- All ancillary procedures and services associated with noncovered GERD treatments must be billed and documented on the same claim as the noncovered procedure.
Key Coverage Criteria
- 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.
- EGD is indicated for persistent vomiting of unknown cause.
2 Active Policies
A56389 — Billing and Coding: Upper Gastrointestinal Endoscopy and Visualization
L34434 — Upper Gastrointestinal Endoscopy and Visualization
Related Codes
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