CPT code 38243 is a medical code used to describe a specific procedure for transplanting hematopoietic cells to enhance recovery.
CPT code 38243 is used to report a transplant-related hematopoietic cell boost procedure, where additional stem cells are collected to enhance the therapeutic effect after an initial transplant.
For CPT code 38243, which pertains to the transplantation of a hematopoietic boost, the following modifiers may be applicable:
1. Modifier 22 (Increased Procedural Services): This modifier is used when the work required to perform the procedure is substantially greater than typically required. This could be due to complications or other factors that increase the complexity of the procedure.
2. Modifier 52 (Reduced Services): This modifier is applicable if the procedure was partially reduced or eliminated at the discretion of the physician. It indicates that the service provided was less than usually required.
3. Modifier 59 (Distinct Procedural Service): This modifier is used to indicate that a procedure or service was distinct or independent from other services performed on the same day. It is often used to bypass National Correct Coding Initiative (NCCI) edits.
4. Modifier 76 (Repeat Procedure by Same Physician): This modifier is used when the same procedure is repeated by the same physician. It indicates that the procedure was necessary to be performed more than once.
5. Modifier 77 (Repeat Procedure by Another Physician): Similar to Modifier 76, this is used when the procedure is repeated, but by a different physician.
6. Modifier 78 (Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period): This modifier is used when a patient requires a return to the operating room for a related procedure during the postoperative period.
7. Modifier 79 (Unrelated Procedure or Service by the Same Physician During the Postoperative Period): This modifier is used when a procedure is performed during the postoperative period of another procedure, but is unrelated to the original procedure.
8. Modifier 91 (Repeat Clinical Diagnostic Laboratory Test): This modifier is used when a laboratory test is repeated on the same day to obtain subsequent (multiple) test results.
These modifiers help provide additional information about the circumstances under which the procedure was performed, ensuring accurate billing and reimbursement. It is important to use them appropriately to avoid claim denials or audits.
CPT code 38243, which is associated with a specific medical procedure, may be reimbursed by Medicare, but this is contingent upon several factors. The Medicare Physician Fee Schedule (MPFS) is a crucial resource for determining whether a particular CPT code is covered and the reimbursement rate. The MPFS outlines the payment rates for services provided to Medicare beneficiaries and is updated annually to reflect changes in policy and practice.
Additionally, Medicare Administrative Contractors (MACs) play a significant role in the reimbursement process. MACs are responsible for processing Medicare claims and have the authority to make coverage determinations based on local policies. Therefore, the reimbursement for CPT code 38243 can vary depending on the region and the specific MAC's guidelines.
Healthcare providers should consult the MPFS and their respective MAC's local coverage determinations to verify if CPT code 38243 is reimbursed and to understand any specific documentation or criteria required for coverage. This due diligence ensures compliance and optimizes the revenue cycle management process for services rendered to Medicare beneficiaries.
Discover the power of MD Clarity's RevFind software to ensure you're receiving the full reimbursement you deserve. With the ability to read your contracts and detect underpayments down to the CPT code level, including specific codes like 38243, RevFind provides unparalleled accuracy and insight. Schedule a demo today to see how RevFind can help you identify discrepancies by individual payer and enhance your revenue cycle management.
Get paid in full by bringing clarity to your revenue cycle
Subscribe to the
Healthcare Clarified newsletter
Get the latest insights on RCM and healthcare policy in your inbox
