Esophagogastroduodenoscopy CPT Code: 2026 EGD Coding Guide

The main CPT code for an esophagogastroduodenoscopy (EGD) is 43235 for a flexible transoral EGD with optional esophageal brushing and/or washing. 43239 is the code for taking a tissue biopsy during the procedure. If another endoscopic procedure (i.e. endoscopic ultrasound (EUS), foreign body removal, or endoscopic procedures to control bleeding or GI obstruction) is performed in conjunction with an EGD, then an EGD code would not be appropriate.

Esophagogastroduodenoscopy (EGD) is made up of a number of specific procedures and the best way to code EGDs is to think of them in this manner. The key to proper coding for EGDs and endoscopic procedures in general is to read the procedure note and determine the specific procedures the physician performed.

EGD CPT Codes: Quick Reference

An upper endoscopy or EGD is a procedure that allows a doctor to assess the esophagus, stomach, and beginning of the small intestine. This is done by advancing a flexible scope through the mouth and swallowing it.

Once the scope is in place, the doctor is able to remove any foreign bodies that are obstructing the GI tract. Additionally, biopsies can be taken, inflated balloons can be used to remove polypoid growths, and sphincter of Oddi manometry can be performed.

The code used is based on the diagnosis for the EGD. For additional work done beyond the diagnostic scope, other codes will be assigned.

Use this table to narrow the choices, not as a replacement for reviewing the complete current CPT descriptor.

CPT 43235 Is the Starting Point for Diagnostic EGD

The code 43235 describes a diagnostic endoscopic evaluation of the upper gastrointestinal tract (upper GI tract). This code is the starting point for coding when an endoscopy of the upper GI tract is performed to just take a look.

upper GI endoscopies are typically performed to obtain a biopsy or to remove an obstruction or other foreign bodies. Codes to describe these types of endoscopic procedures are more specific and may carry a higher level of reimbursement.

A biopsy may be performed as part of a diagnostic endoscopic procedure; however, obtaining a biopsy sample does not convert the code for this service to 43239.

In order to assign 43235 for a diagnostic endoscopic evaluation, the endoscopist must provide the reason for the evaluation as well as the extent of the evaluation. In addition, relevant findings, as well as whether brushing or washing was performed, must be included. The presence or the absence of other procedures, as well as the reason for stopping the procedure, should also be documented and reported.

When the only comment in the documentation is “EGD performed,” the coder must make many assumptions regarding the reason, extent, and findings of the procedure.

Brushing, Washing, and Biopsy Aren’t the Same Thing

This distinction is important for correct coding, and provides many opportunities for particular examples.

Let’s start with an abnormal area found in the esophagus. The physician collects cells from this area with a brush and sends the cells for further analysis. The physician does not perform an endoscopic tissue biopsy.

It is important to note that collection of cells for analysis does not mean a biopsy EGD was performed and code 43235 is appropriate. Code 43235 may still apply in this situation.

Let’s say we have a different situation where a biopsy forceps is used by the physician to remove abnormal tissue from the esophagus.

In this instance, code 43239 is appropriate.

The general rule in these cases is to go beyond the simple question “was a specimen collected?” The question to answer is “how was the specimen collected?”

Choosing Between 43235 and 43239

These codes tend to be confusing to the provider and the practice because the details about the two types of exams are wrapped in the same code description.

The difference is the additional work.

CPT code 43239 is assigned when a physician obtains a biopsy specimen during an EGD. However, just because a specimen is obtained during an endoscopic procedure and sent to Pathology, does not mean that an EGD should always be assigned during an endoscopic procedure coding review. There may be instances when a physician performs an EGD and obtains multiple biopsy specimens, and later performs a colonoscopy, and removes a polyp (or polyps) and sends the specimen(s) to Pathology. In both of these examples, the procedures performed dictate the CPT codes assigned. There are situations when, due to the nature of the specimen(s) obtained for Pathology, there is confusion as to what procedure was performed. This is often resolved by Pathology Billing Services staff during the course of a review of the specimen, the Pathology report, and supporting procedures documentation.

Example: Gastric Biopsies Taken During EGD

An EGD is performed on a patient to evaluate the cause of persistent upper GI symptoms. The physician finds irregular gastric mucosa and collects specimens by biopsy.

Here is the coding rationale:

• A diagnostic endoscopic examination of the upper gastrointestinal tract (EGD) was performed.
• Biopsy of the tissue was performed.
• A number of tissue specimens were taken.
• Taking several specimens during the same biopsy service is considered one biopsy service.
• The biopsy service is part of a more comprehensive procedure of diagnostic endoscopic examination.
• The correct CPT code is 43239.

The procedure note should describe the biopsy site and biopsy method.

Therapeutic Work Moves the Claim Beyond 43235

There is a tendency in some practices to put code 43235 on every EGD claim.

This is not the correct way to think about this family of codes.

In general, if the diagnostic EGD is to facilitate a therapeutic EGD, and the EGD service includes the therapeutic component, then the diagnostic component is encompassed in the EGD service and therefore does not need to be reported separately.

Some examples of therapeutic EGD services are:

• Dilations
• Embolizations
• Coagulations
• Resection of Lesions
• Removal of Foreign Bodies
• Placement of Gastrostomies/Jejunostomies and Other Enterostomies
• Stent placements
• Ablations
• Endoscopic Ultrasounds.

If a Physician finds a stricture during an EGD and performs a dilation to treat the stricture, code 43235 should not be reported since the service was the dilation and not the EGD.

An exception to the “one EGD, one code” rule is if there are multiple distinct EGD services performed, even if done on the same patient, they may each be reported. Whether two or more EGD services may be reported depends on a number of factors including medical necessity, reason for the EGDs, Code combination, and payer rules. The EGDs may not always be bundled and reported as a single service. The same principles would apply to a family of codes other than the EGD family.

Dilation Coding Depends on More Than the Word “Dilation”

A note saying “EGD with dilation” gives very little information to the coder.

A lot of additional details are needed including:

• What was dilated?
• Where was the narrowing?
• What kind of dilation was performed?
• Was a guidewire used?
• What kind of balloon was used, if any?
• What was the size or what kind of device was used?

Esophageal or gastric dilation is coded differently. Duke’s dilation is coded differently as well.

An Example: EGD with Esophageal Balloon Dilation

A patient was seen with a swallowing difficulty due to a narrowing of the esophagus. The physician performs an EGD and places a esophageal balloon to dilate the narrowing. No biopsy is performed.

The EGD portion of the procedure codes the diagnostic portion of the procedure. The balloon dilation portion of the procedure codes the procedure to treat the esophageal narrowing.

A through the scope esophageal balloon dilation would be coded 43249 in the evaluation portion of the procedure and 43211 in the treatment portion of the procedure, based on the information provided by the physician and the CPT coding description.

EUS Requires Its Own Coding Review

Being that the anatomical path taken during an Endoscopic Ultrasound (EUS) and an Esophago-Gastro Duodenoscopy (EGD) are the same, EUS should not be coded as a plain EGD.

During EUS, a number of variables should be considered, including:

• Degree of the ultrasound examination
• Structures visualized
• Whether ultrasound sampling was performed
• Type of sampling
• Target of sampling

Each of the above variables can affect the appropriateness of various codes, e.g. 43237, 43238, or 43242.

Notations such as “EGD/EUS performed” are of no value in coding. Documentation should include the details of the ultrasound examination, including description of any sampling.

How the Codes are Interpreted Changes the Logic for Billing

Coding 43235 is often difficult for new coders. This code shouldn’t be interpreted to require that a diagnostic EGD always be reported in addition to a more comprehensive EGD.

If a diagnostic endoscopy is performed to assist in a therapeutic endoscopic procedure, the diagnostic endoscopy shouldn’t be reported. In these situations, 43235 is considered the diagnostic component of the overall endoscopic procedure.

A complete EGD should include an evaluation of the esophagus and the stomach. If the esophagogastrouduodenoscopy (EGD) is performed for diagnostic purposes only, an evaluation of the upper GI tract is complete, and 43235 is considered a comprehensive service, then the code should be assigned.

If, however, the EGD was performed to evaluate the esophagus and the stomach, and a biopsy of an ulcer was performed, code 43235 would represent the diagnostic component, and an additional code for the biopsy would also be reported.

NCCI Edits Need to Be Checked Before Adding Another Code

memory alone shouldn’t inform bundling decisions.

When you see two EGD procedures in the same operative note, you should ask the following:

• Is there an active procedure-to-procedure edit that applies?
• Is the first procedure a part of, or a result of, the second?
• Were two different techniques performed on different lesions?
• Is the distinction between the two clearly communicated?
• Is there a circumstance in which each procedure was performed that justifies the use of a modifier?
• Would the payer allow the modifier?

Payer policy directly affects bundling decisions. While it is important to consider the policy of all payers, particularly Medicare, it is equally as important to consider the policy of the payer that has the greatest financial exposure to the given claim.

A modifier should only be used to describe the clinical situation if it is warranted. A modifier should not be used to bypass an editing system.

EGD Modifiers That Need Extra Attention

Modifier 52: Decreased Medical Service

Use Modifier 52 when a service is performed to a lesser degree.

If only a portion of an EGD is performed, document the extent of the EGD performed.

Document the reason the remaining portion of the EGD was not performed.

Using the code “Procedure incomplete” provides no information and does not justify why the entire EGD was not performed.

Modifier 53: Discontinued Procedure

Use Modifier 53 when the performing of a procedure is stopped because of a potential safety concern to the patient.

The reason the procedure was stopped must be explained and documented, as well as the extent of the procedure performed.

Modifier 52 and 53 are not interchangeable.

Modifiers 73 and 74 in the Facility Setting

Modifiers 73 and 74 may be used in an outpatient surgery center to indicate the procedure was begun but not completed because of a safety concern to the patient.

If a procedure is not completed, the surgery center may bill for the procedure to be completed, and the physician may also bill for the incomplete procedure. Because the same procedure is being performed, and documented, both the Surgery Center and the Physician may need to use Modifier 53 to indicate the procedure was discontinued.

Modifier 59: Distinct Procedural Service

There are situations where two EGDs are performed, but because of bundling, only one code is allowed. Use Modifier 59 to indicate the EGDs were distinct and performed as separate services.

If the situation is being reviewed for reimbursement, Modifier 59 may not be the only modifier used to justify reimbursement. XE, XP, XS or XU may also be more applicable, depending on the situation.

If the case record review (CFR) doesn’t show separation, there are no options other than to omit the modifier and address the separation issue.

Modifier 51 Won’t Fix Bundling

Modifier 51 pertains to different surgical procedures. It will not override bundling of services due to coding edit.

The presence of two procedures in a surgical report does not allow adding Modifier 51.

Check the code level relationship first.

Modifier 33 and PT Require the Right Preventive Context

Preventive service modifiers are evaluated by payers and may not warrant medical necessity.

It is important to evaluate the context of the service to see if it warrants medical necessity. Coverage for an EGD may not always be the same as a screening colonoscopy.

A Procedure Note Should Tell the Whole Coding Story

It is important to think about EGD coding as early as the point at which the record is created in the clinic, rather than when the record is handed off to the billing department.

The EHR should contain sufficient information for the medical coder to identify the correct code without the coder having to piece the information together themselves.

Clinical Indication

An appropriate EGD code requires the medical coders’ understanding of the reason for the EGD. Some examples of clinical indications include: persistent or unexplained symptoms; abnormal imaging; GI bleeding; and an unexpected finding on endoscopic exam, etc.

Extent Reached

It is important to document the extent of the scope examination. This is particularly important for partially completed examinations.

Findings by Location

Rather than documenting “abnormal findings,” the anatomic location of the abnormality should be documented. Additionally, the finding may vary based on the technique performed.

Technique Used

There are many techniques that may be employed during an EGD. These include washing, brushing, biopsy, injection, dilation, hemostasis, removal of a foreign body, stent placement, ablation, or EUS.

Lesion and Site Details

If more than one technique is employed, each should be related to a specific finding and/or lesion.

Specimens

The location from which the specimen was obtained should be documented.

Incomplete Procedures

If a procedure is terminated before completion, the reason for the interruption and the extent to which the procedure was completed should be documented. This would assist the coder in selecting the most appropriate code to be assigned to the service.

ICD-10-CM Coding Must Match the Reason for the EGD

There are no diagnosis codes that are automatically associated with esophagogastroduodenoscopy (EGD) codes.

The diagnosis code is based on the patient condition, symptoms, or findings that warrant the EGD.

Examples of conditions requiring an EGD may include:

• Swallowing difficulties (dysphagia)
• Gastrointestinal (GI) bleeding
• Heartburn
• Stomach or small intestine (duodenal) ulcers
• Stomach or intestinal (gastric or duodenal) inflammation
• Esophageal cancer, premalignant changes or Barrett’s Esophagus
• Anemia
• Celiac disease
• Abnormal x-ray or endoscopy findings
• Other abnormal findings
• Surveillance of prior condition

The diagnosis code is assigned based on the condition documented in the medical record.

It is inappropriate to select a diagnosis based on the CPT code and/or EGD findings to see if it supports medical necessity to perform the EGD. The code assigned should reflect the clinical condition for which the EGD was performed.

Medical Necessity Goes Beyond Matching Two Codes

An ICD-10-CM code and CPT code can appear to be a medical necessity to you and a payer and still be denied.

Reasons for EGD in this case need to be documented.

Let’s say you have a patient with a complaint of swallowing issues (dysphagia). Just putting a dysphagia code on the claim may not tell the story and raise concern for medical necessity for an EGD. The reason for the EGD may not be documented and/or explained in the chart.

Repeat and Surveillance EGDs also need to be supported with rationale.

The same applies for other exams and tests. Reason for the test and the outcome and/or the symptoms that warranted the exam needs to be supported and documented.

Medicare and Commercial Payers Can Process the Same EGD Differently

Correct CPT coding does not ensure payment.

A payer can evaluate the following:

• A referral or other authorization may not be required. However, the payer may consider medical necessity.
• The payer may assess frequency and determine if the place of service is appropriate.
• Modifiers and documentation may be reviewed to determine if a service is excluded from the payer’s benefits.
• The payer can also review a beneficiary’s coverage limitations.
• Payment by Medicare also relies on other factors, such as the location of the service and the nationwide fee schedule adjustments.
• Payments by other health plans and contracted insurance companies are determined by the terms of the plan, contract, and/or employment.

For this reason, it is misleading to state a single, defined reimbursement amount for CPT code 43235.

A more appropriate question is, What terms define reimbursement for this code, in this situation?

Professional and Facility Claims Don’t Work the Same Way

Performing an EGD at an ambulatory surgery center or hospital allows the center to generate a variety of claims.

The physician reports the professional service and is typically paid at the facility rate. Whether the facility has a separate claim processed and paid under the applicable payment methodology impacts reimbursement and modifier decisions.

The rules for EGD claims depend on who is primarily billing the service. ASCs and hospitals each have specific rules.

The rules for EGD claims are the same as the rules for upper gastrointestinal (UGI) endoscopy claims and are similar to the rules for colonoscopy claims. Each of these procedures must be performed by a physician and in a specific location in order for the claiming entity to comply with the rules.

Moderate Sedation Isn’t Automatic

We’ve discussed some of the assumptions that can lead to misinterpretation when applying code definitions. Sedation is another good example. Moderate sedation is the most common level of sedation in EGDs.

Even if a patient was sedated for an EGD, a moderately sedation code would not necessarily be assigned.

A variety of factors influence the coding decision, including:

• who performed the sedation?
• was the time the sedation was performed documented?
• what are the payer’s requirements?
• was an anesthesia professional involved?
• what are the scope’s supervision and documentation requirements?

Moderate sedation is defined as a service that is separate from the EGD when the endoscopist personally performs the service. In these instances, documentation would support the endoscopist provided a moderate sedation service beyond the EGD.

The time the sedation is performed is different from the time the procedure is performed, and sedation time is not automatically equivalent to total procedure time.

Coding Errors That Commonly Turn Into Denials

BILLING 43235 AND 43239

The code for esophagogastroduodenoscopy (EGD) with biopsy (43239) includes the code for an EGD with biopsy removed (43235).

Do not assign 43235 when the physician performing the EGD removes the specimen.

Treat all specimens as potential biopsies

Biopsies are one of several methods to obtain tissue. The other methods are washing and/or brushing.

Assign 43239 only when a biopsy is performed.

Reporting more than One Unit for more than One Biopsy

Just because more than one biopsy specimen is removed, does not mean that more than one unit of 43239 is reported.

Coding Based on the Scheduled Procedure

An EGD with potential biopsy on the schedule means a biopsy may be performed.

A biopsy was performed if the specimen was removed.

Coding the biopsy is appropriate.

Use of Modifier 59 After Bundling

Just because a bundled service was denied does not mean a modifier is warranted.

Review the documentation to determine the reason for the denial.

Failure to Code the Dilation Procedure

EGD with dilation of a sphincter requires a review of the procedure to determine the anatomic site.

The code may also depend on the method and technique used.

Assuming the Procedure was Complete

If the endoscopist was unable to complete the EGD, it may also affect the other codes assigned on the claim.

Reliance on a Single Payment Estimate

There is not a national payment amount for EGD procedures.

Payment may depend on the location where the service was performed, the year, and the payer.

A Practical Pre-Bill Checklist for EGD Claims

Before releasing the claim, check the following.

Procedure details

• Was the EGD transoral?
• How far did the scope advance?
• Was the examination completed?

Work performed

• Diagnostic examination only?
• Brushing or washing?
• Biopsy?
• Injection?
• Dilation?
• Bleeding control?
• Lesion removal?
• Foreign-body removal?
• EUS?
• Stent or ablation?

Code selection

• Does the CPT code describe the actual technique?
• Is a diagnostic code being added to a more specific service without justification?
• Are multiple units genuinely supported?

Bundling

• Was the relevant code combination checked?
• Are separate sites or lesions clearly documented?
• Is a modifier supported rather than merely convenient?

Diagnosis and coverage

• Does the diagnosis reflect the medical record?
• Is the procedure medically necessary under the applicable payer policy?
• Was authorization required?

Documentation

• Indication documented?
• Extent documented?
• Findings documented?
• Technique documented?
• Sites identified?
• Specimens identified?
• Reason for discontinuation documented when relevant?

A short review at this stage is usually easier than reconstructing the same information after a denial.

A Better Way to Work an EGD Denial

When a claim for an endoscopy gets denied, changing the CPT code for the procedure is not the first step that should be taken.

The message for the denial should be reviewed first. Denial messages for endoscopy procedures typically fall into one of three categories: medical necessity, prior authorization, and payer-specific.

Read the Payer’s Reason

Identify the reason for the denial (i.e. medical necessity, authorization, coverage, bundling, diagnosis linkage, documentation, etc.)

Knowing the denial reason is crucial in resolving the denial.

For example, if the reason for the denial states that medical necessity was not met, the adjudicator will examine the evidence to determine if medical necessity was in fact not met.

Claim and Procedure Note Discrepancy

If the claim describes a code as 43235 and the operative report describes a biopsy as being done by forceps, check to see if the biopsy code was incorrectly coded.

If the claim describes a code as 43239 and the report describes no biopsy, then that is an error in reporting the biopsy.

Review Bundling Before Applying a Modifier

If a review determines that one service has been denied as part of another service, and the two services are in fact the same, then the two procedures should be considered as one.

A modifier should not be applied to a claim if theModifier alters the meaning of the claim to allow the claim to pass the edits.

Recheck Diagnosis Coding

Review the documentation and confirms the diagnosis submitted is supported by the reason for the procedure (if required to be submitted by the payer).

Choose Corrected Claim or Appeal

You can choose to re-open your claim if you think your coding was inaccurate and needs to be corrected.

If, however, your coding was correct, and there is sufficient documentation to support that the service was furnished, an appeal may be your best option.

Remember, these are two completely different options with no relation to one another.

Real-World Coding Scenarios

Diagnostic EGD with Esophageal Brushing

This code describes an EGD performed on a patient with dysphagia. The physician will evaluate the esophagus, stomach, and duodenum and take cell samples with an esophageal brush. No tissue biopsy or other procedures will be performed.

Guidance: Report 43235

A brushing of the esophagus does not change the description of the code to 43239.

EGD With Multiple Gastric Biopsies

During an EGD, if the physician identifies abnormal gastric mucosa, multiple biopsy specimens will be taken.

Coding direction: 43239

The number of specimens taken doesn’t guarantee multiple services were performed.

EGD With Guidewire Dilation

The insertion of a guidewire is a common technique used to treat esophageal strictures.

Coding direction: 43248 is designated as the more specific code and should therefore take priority.

The technique used in this case modifies the nature of the EGD from a simple diagnostic EGD to a more interventional EGD procedure.

EGD Interrupted for Patient Safety

A procedure is begun but is terminated due to patient safety. The reason for the interruption is documented as well as the farthest extent of anatomy reached.

Interpretation: Determine the procedure performed and the reason for its discontinuation.

Rationale: The termination of the procedure likely occurred due to the presence of adverse clinical conditions. As such, the discontinued EGD may be appropriate for reporting and reimbursement.

Separate Lesions Treated With Different Techniques

During a single endoscopy (EGD), the physician treats multiple lesions using various endoscopic techniques.

Coding Direction: Not every procedure performed should automatically be submitted. Likewise, only a single procedure should not be assumed. Evaluate payer policy, bundling rules, the context of the documentation, and the rationale supplied by the coder to support reporting of multiple sites or techniques.

Fast EGD Code Selection Workflow

When reviewing the operative report, consider the following stepwise example to document the endoscopic procedure:

Diagnostic visualization with possible brushing/washing
→ Document evaluation of code 43235

Tissue biopsy
→ Document evaluation of code 43239

Injection performed
→ Document evaluation of code 43236

EUS performed
→ Proceed to EUS codes

Dilation performed
→ Document the anatomy and method of dilation

Foreign body retrieval
→ Document foreign body retrieval

Bleeding control
→ Document bleeding control

Tissue removal
→ Document the method of tissue removal

Stent placement or tissue ablation
→ Document the code for the ablation or stent placement

Various procedures
→ Review bundling and payer guidance before documenting multiple procedures.

The guidance is based on the endoscopic procedure documented in the procedural note.

Frequently Asked Questions

Which CPT code should I use for a routine diagnostic EGD?

CPT 43235 is generally used for a diagnostic flexible transoral EGD when no biopsy or other intervention changes the service. Brushing or washing can be included. Always review the complete procedure note because biopsy, dilation, EUS, bleeding control, or another intervention may require a different code.

Is 43235 still correct if the physician collects a specimen?

It can be. The deciding factor is the collection technique. Brushing or washing may fall within 43235, while tissue obtained through biopsy generally points to 43239. Don’t code from the word “specimen” alone. Check exactly how the physician obtained it.

Can 43235 and 43239 go on the same claim?

Usually, the diagnostic 43235 service isn’t separately reported when the same EGD proceeds to a biopsy represented by 43239. If other endoscopic services were performed, evaluate the specific code combination, bundling rules, distinct sites or lesions, documentation, and payer policy before reporting multiple codes.

Do multiple biopsy sites mean multiple units of 43239?

Not simply because several specimens were collected. CPT 43239 describes biopsy involving single or multiple tissue sampling within the applicable procedure. The operative report should identify the sites sampled, but several biopsy specimens don’t automatically justify several units of the code.

Which modifier should be used when an EGD can’t be completed?

There isn’t one modifier for every incomplete EGD. Modifier 52 may apply to reduced services, while 53 may be relevant when the physician discontinues a procedure for qualifying circumstances. ASC reporting can involve 73 or 74. The reason, timing, billing entity, and payer rules determine the correct approach.

Is modifier 59 allowed with EGD codes?

Modifier 59 may be appropriate when separately reportable services are genuinely distinct and the documentation supports that distinction. It shouldn’t be added simply to bypass a bundling edit. Depending on the circumstances and payer, a more specific XE, XP, XS, or XU modifier may apply.

Which ICD-10 code should be paired with CPT 43235?

There is no single ICD-10-CM code that universally belongs with 43235. Diagnosis coding should reflect the documented reason for the EGD, such as dysphagia, GI bleeding, ulcer disease, reflux-related disease, or another supported condition. Coverage requirements can vary by payer.

Does Medicare cover EGD as a routine screening procedure?

Routine upper GI endoscopy shouldn’t automatically be treated like Medicare colorectal cancer screening. Coverage typically depends on a documented medically necessary indication or applicable surveillance circumstance. Check the patient’s clinical indication and current payer requirements before treating the service as preventive.

The Takeaway Before You Submit the Claim

When determining which CPT code to select for esophagogastroduodenoscopy (EGD), 43235 is the starting point, but there may be additional codes to report as well.

CPT code 43235 is appropriate to report for a diagnostic EGD that may include brushings or washings. If a biopsy is performed and tissue is removed, report code 43239. If the service performed is beyond diagnostic, such as dilation, EUS, hemostatic procedures, foreign body removal, lesion removal, stent placement, ablation, or other interventions, code the service performed and document.

Prior to allowing a claim, the following should all align:

• The medical record documentation
• The CPT code reported
• The diagnosis(es)
• The modifier(s) and other edit junk
• The payer’s requirements

Insurers will look for medical necessity and proper coding, editing, and bundling. Having these aligned will improve the likelihood the claim will not be denied.