Mar 19th, 2019 - ChrisW 256 1
This is a great question. An NCCI edit exists when reporting 43237 and 43239 - If both 43237 and 43239 are submitted, only 43237 will be paid, you cannot bill for two EDG’s and you will not get paid for the biopsy if you only report 43237 because of the NCCI edits.
43239 is a column 2 edit with an NCCI edit #1, stating it is not payable unless an NCCI associated modifier is both appropriate and allowed. Therefore, if it is s separate encounter or a separate structure then the modifier may be used. Both codes include the same structure and I am assuming this was all done at the same time, so in this case, a modifier would NOT be appropriate. If you report modifier 59, this is considered unbundling and would not be correct coding.
43238 – includes the Ultrasound-guided FNA, which you said there was no FNA done. (Therefore, this would not be the correct code to report).
Because of the NCCI Edits and from the information you have given me the only code that should be reported is 43237.
It seems backward because the RVU’s and the cost is higher with the Biopsy code 43239, but the edits are clear, and it may be perhaps due to the risk of the Ultrasound being lower than the biopsy, so in this case it does not look like the provider will be reimbursed for the biopsy(s).