LCD Reference Article Billing and Coding Article

Billing and Coding: Endoscopic Treatment of GERD

A56395

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

Document Note

Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A56395
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Endoscopic Treatment of GERD
Article Type
Billing and Coding
Original Effective Date
03/28/2019
Revision Effective Date
10/01/2023
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1862(a)(1)(A). Allows coverage and payment for only those services that are considered to be reasonable and necessary.

Title XVIII of the Social Security Act, §1833(e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Change Request 10901 Local Coverage Determinations (LCDs) Implementation date January 8, 2019.

IOM 100-08 Medicare Program Integrity Manual, Chapter 13-Local Coverage Determinations.

Article Guidance

Article Text

The billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD L34659.

Benefits are not available for endoluminal treatment for Gastroesophageal Reflux Disease (GERD) using the Stretta® procedure, the Bard EndoCinch™ Suturing System, Plicator™, or similar treatments as these procedures are not considered reasonable and necessary for the diagnosis or treatment of an injury or disease.

Currently, these procedures are considered non-covered due to the fact that current peer-reviewed literature does not support the efficacy of the services. Claims will be denied as “not proven effective.”

Coverage is appropriate for the TIF (Transoral Incisionless Fundoplication) procedure, example EsophyX™, documentation must support the indications listed in L34659.

Documentation Requirements
The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See the Coverage Indications, Limitations and/or Medical Necessity). This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures, and any other records that describe or support the evaluation and treatment of the patient. Documentation should be available to the Contractor upon request.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
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Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

(4 Codes)
Group 1 Paragraph

Non-covered

Group 1 Codes
Code Description
43257 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH DELIVERY OF THERMAL ENERGY TO THE MUSCLE OF LOWER ESOPHAGEAL SPHINCTER AND/OR GASTRIC CARDIA, FOR TREATMENT OF GASTROESOPHAGEAL REFLUX DISEASE
43499 UNLISTED PROCEDURE, ESOPHAGUS
43999 UNLISTED PROCEDURE, STOMACH
49999 UNLISTED PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM

Group 2

(1 Code)
Group 2 Paragraph

EsophyX™: Coverage is appropriate for indications listed in L34659.

Group 2 Codes
Code Description
43210 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ESOPHAGOGASTRIC FUNDOPLASTY, PARTIAL OR COMPLETE, INCLUDES DUODENOSCOPY WHEN PERFORMED
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(3 Codes)
Group 1 Paragraph

The ICD-10-CM diagnosis codes in Group 1 below support the medical necessity of CPT code 43210

Group 1 Codes
Code Description
K21.00 Gastro-esophageal reflux disease with esophagitis, without bleeding
K21.01 Gastro-esophageal reflux disease with esophagitis, with bleeding
K21.9 Gastro-esophageal reflux disease without esophagitis
N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
XX000 Not Applicable
N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code Description
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
N/A
Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
10/01/2023 R6

Posted 12/28/2023 Under CPT/HCPCS Codes Group 1 codes, CPT codes 43499, 43999, and 49999 had description changes effective 10/01/2023.

09/29/2022 R5

09/29/2022-Review completed 08/15/2022 with no change in coverage.

02/14/2021 R4

12/31/2020 See LCD L34659 for coverage changes based on a valid reconsideration request. No changes to coding.

10/01/2020 R3

10/29/2020: ICD-10 CM code update: added K21.00, K21.01, and K21.9; effective 10/01/2020. Review completed 09/17/2020.

11/01/2019 R2

Content has been moved to the new template.

11/01/2019 R1

Content has been moved to the new template.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
https://www.ssa.gov/OP_Home/ssact/title18/1862.htm
Description: Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.
https://www.ssa.gov/OP_Home/ssact/title18/1833.htm
Description: Title XVIII of the Social Security Act, Section 1833(e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
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CMS Manual Explanations URLs
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2019Downloads/R854PI.pdf
Description: Change Request 10901 Local Coverage Determinations (LCDs) Implementation date January 8, 2019.
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Other URLs
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Public Versions
Updated On Effective Dates Status
12/20/2023 10/01/2023 - N/A Currently in Effect You are here
09/20/2022 09/29/2022 - 09/30/2023 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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