Reimbursement

EndoGastric Solutions (EGS) has a dedicated team of specialists available to help you and your GERD patients communicate the value of transoral incisionless fundoplication (TIF) to key decision makers at your third party payers.

The goal of the team at EGS is to help your practice gain authorization and reimbursement. This process familiarizes payers with the TIF procedure and, over time, works to expand medical policy coverage.

+-What is the new Category 1 CPT code that describes the TIF procedure?

CPT 43210 EGD esophagogastric fundoplasty is the short form descriptor.
As of January 1, 2016 the code is in effect. This has been published in the AMA Professional Edition CPT® (Current Procedural Terminology) 2016 manual.

+-Will physicians be able to bill separately for EGDs pre and post TIF procedure?

When EGD is performed the same day as part of the TIF procedure it is not to be billed separately—it is part of the descriptor for 43210.

If there’s an EGD performed as part of the diagnostic work up and/or in a follow-up visit separate from the TIF procedure day, then it could be billed separately.

+-What’s the meaning and implication of CPT 43210 having a 0 global period?

CPT 43210 reports a 0 global period. This means physicians are allowed to separately bill for patient’s post-procedure related follow-up visits, including the discharge visit.

+-What is a global period?

The global period refers to payments for total episodes of care specific to a procedure. Other procedures have global periods that are longer which mean that payment includes follow-up visits. This is not the case for 43210.

+-Is anesthesia bundled into CPT 43210?

No. Anesthesia is billed separately by the hospital and anesthesiologist.

Downloadable PDF: 2016 CPT Quick Coding Reference

EGS offers two levels of services:

Consultative Services: EGS provides the tools and training that enables practices to complete their own pre-determinations
Support Services: EGS works in partnership with the practice to execute pre-determinations and all levels of internal and external appeal

Support Services involve the following:

Pre-Authorization including Pre-Determination: EGS offers a full service TIF Authorization Assistance Program, which includes launching a pre-authorization and pre-determination request. This process ensures the payer reviews the patient’s medical necessity and individual health benefits prior to surgery.
Internal Appeal: If a pre-authorization is denied, our goals as a certification team are to get the patient through all levels of internal appeal as quickly as possible and to communicate concisely with all stakeholders involved in the process. Our practice advocates will assist by providing individualized appeal letters, proactive payer follow-up and support, as well as talking points for peer review.
External Medical Review: EGS supports the practice and patient through an external medical review by providing process guidance to the patient, talking points for review and a medical literature archive.

At EGS, we are dedicated to advancing surgical intervention for the treatment of GERD. Together, we can educate payers on the limitations associated with open and laparoscopic surgery and help them better understand the benefits of an incisionless approach to fundoplication. We stand ready to assist you and help your patients gain access to the most appropriate therapy.

For authorization assistance, contact us at:
Phone: (860) 619-4133
Fax: (860) 215-8108

NP02410-06A
NP02432-06D
NP02477-04A

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