Friday, March 10, 2017

CPT 43210, 43499, 43999 - TIF procedures

CPT/HCPCS Codes


43210 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; WITH ESOPHAGOGASTRIC FUNDOPLASTY, PARTIAL OR COMPLETE, INCLUDES DUODENOSCOPY WHEN PERFORMED

43499 UNLISTED PROCEDURE, ESOPHAGUS

43999 UNLISTED PROCEDURE, STOMACH

Coverage Indications, Limitations, and/or Medical Necessity

Background

The TIF (Transoral Incisionless Fundoplication) procedure is promising for treatment of patients in whom proton pump inhibitor therapy fails. Clinical data from various studies are emerging. At this time, open-label studies or patient registries with short term follow-ups are the dominant source of data. The preponderance of reviewers remain equivocal in their support and have called for randomized controlled trials with long-term follow-ups.

An example of the device used in TIF is EsophyX ™. TIF using EsophyX ™ for performing surgery for treating gastroesophageal reflux disease (GERD) reconstructs the valve at the top of the stomach that helps prevents acid reflux.

Indications

Coverage is appropriate for TIF if done by a well trained surgeon for the following indications:

Symptomatic chronic gastroesophageal reflux (chronic being defined as > 6 months of symptoms), and

Symptoms must be responsive to Proton Pump Inhibitors (PPIs) as judged by GERD HRQL scores of < or equal to 12 while on PPIs and > or equal to 20 when off for 14 days (also acceptable would be the difference of > or equal to 10 of the scores between off and on therapy), and

Hiatal hernia < or equal to 2 cm, if present.


Limitations

Coverage is not extended:

for those patients who may have recurrent symptoms or may fail this procedure. No literature has been submitted for repeat TIF use. These procedures (repeat TIF) would be considered investigational at this time.

for those patients in which a staged procedure is being done, as described as a laparoscopic esophageal or paraesophageal diaphragmatic hernia / opening closure followed by a TIF endoscopically.



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 policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
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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 policy, 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 policy should be assumed to apply equally to all Revenue Codes.

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