# Please,Please Help Me



## bcanupp (May 8, 2015)

First, let me say thanks in advance for anyone that can help me!!!! I am new to most of this and not really a coder but I'm trying to help my others that are.

We have a gastro guy that does his scopes at the hospital and obviously consults quite a bit over there. Anyway the patient comes to ED on 3/25 with bleeding and he was admitted and received 2 units of blood and admitted and my GI guy was called for consult. Patient has liver cirrhosis, kidney disease and prior history of gastro bleeding but is a new patient to us. Also, has diabetes, morbid obesity and hypertension just to make life easier.  My gastro doc does an upper gi endoscopy on same day and bills a 43235 to Medicare and the consult of 99223. There were esophageal varices but no active bleeding.

Next day 3/26/2015 we do a colonoscopy with biopsy because of a liquid bowel movement consisting of blood. Billed a 45380-59. Also did an upper GI endoscopy/ligation,43244-59, found 2 columns of grade 3 varices that were banded.His FFP had to be corrected before the banding could be done. 

Medicare denied the initial 43235 upper gi with a CO-B10 code. Have not been paid for any of the other billing or received any denials yet. Also, if you are inclined to help, could you please direct me towards some GI Billing resources for my coding person.   AGAIN THANKS IN ADVANCE FOR ANYONE TRYING TO HELP ME DECREASE MY LEVEL OF GI IGNORANCE.


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## Cynthia Hughes (May 8, 2015)

Not sure about reason for denial. Would have expected procedure to pay and if no modifier 25 appended, E/M to deny. You can find some coding resources at http://www.gastro.org/practice-management/coding and http://www.asge.org/practice/practice-management.aspx?id=84 that may help. If the physician is a member of AGA or ASGE, he/she can submit questions for help from their professional coding experts. Sorry not more help.


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## BenCrocker (May 8, 2015)

Denial Code (Remarks): CO B10
Denial reason: Allowed amount has been reduced because a component of the basic procedure/test was paid. The beneficiary is not liable for more than the charge limit for the basic procedure/test.
Denial Action: Always payment has been reduced for multiple procedure. While submitting the multiple procedure, submit the high amount line item in first.

Found here.


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## bcanupp (May 11, 2015)

*Help*

Ben thanks in advance and I know what the CO-B10 denial means but I want to figure out how to get it paid.


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## mitchellde (May 11, 2015)

They are indicating that the initial UGI is not payable because the very next day you performed the UGI again with a procedure.  You stated the first one showed no varices and yet the next day you scoped and banded them.  You cannot perform a scope to look one day and then next day perform the same scope with a procedure.


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## bcanupp (May 11, 2015)

*Help still*

The consult and initial upper were on separate claims and then those on the 26th were billed together but on a claim for the 26th.


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## mitchellde (May 11, 2015)

Yes but they were a day apart.  Even though there is no global, they are still going disallow the initial "look" when you went back the same route the next day to perform a procedure.  The logic being the procedure could have as easily been performed the initial scope.  The patient condition did not change significantly from one day to the next.  If you have a good reason why it was unsafe for the patient to have the banding performed during the initial scope then you will need to have that in the notes and appeal.  If the provider made the decision to just wait until the next day, then the initial is not going to be paid.


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## MRBROWN1582 (May 13, 2015)

The procedures on 3-26-15 will get denied with the 59 modifiers. There is no need for the 59 modifer when they are at two different body parts. 59 is only used when you do an additional procedure in the same location. The 59 is so that they dont bundle them toghter as one procedure. It is not needed on a EGD with a colonoscopy.


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## teresabug (May 13, 2015)

I disagree Mr. Brown. A patient can have an excision on the leg and one on the arm. Same CPT, same size. If you billed the 2 charges with no 59 on the second charge the payer will deny it as a duplicate claim. The description of 59 is a "distinct procedure or independent from another procedure. Also, "documentation must support a different SESSION, different proc or sx, different SITE or organ system, separate INCISION or EXCISION, separate LESION..." 

Teresa


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## MRBROWN1582 (May 13, 2015)

Yes Teresa that would be true if they were the same CPT code but this is a COLON and an EGD they are not the same CPT codes therefor no 59 modifier is needed on both procedures as she stated she put


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## teresabug (May 13, 2015)

please re-read the descriptor and guidelines for modifier 59. You are not correct in your post. It has absolutely nothing to do what you are talking about.


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## MRBROWN1582 (May 13, 2015)

I code and bill for GI everyday. To answer the question on the second billed egd the next day modifier XE would need to be used and enter the time of the procedures in the comment field. GI also codes with XS instead of 59 modifier for Seperate Structure. These are the correct modifiers that replaced 59 for GI billing effective 1-1-15   XE-Separate Encounter   XS- Seperate Structure  XP- Seperate Practitioner XU- unusual non- overlapping service.


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## mitchellde (May 13, 2015)

MRBROWN1582 said:


> Yes Teresa that would be true if they were the same CPT code but this is a COLON and an EGD they are not the same CPT codes therefor no 59 modifier is needed on both procedures as she stated she put



This is absolutely correct.  The scenario given by Teresa is totally different than the one described by Mr Brown.  For skin lesions, since skin one one organ you use the 59 modifier to indicate different sites of the skin, or the XS.  However with the EGD and the colonoscopy, by definition these procedures will never be bundled together so no modifier is needed.  At no time can one of these be performed via the other route. Meaning you cannot examine the esophagus via a colonoscopy... Ever!   So no modifier is ever needed for these two procedures performed on the same day.


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## teresabug (May 14, 2015)

"There is no need for the 59 modifer when they are at two different body parts. 59 is only used when you do an additional procedure in the same location." this statement is not true in all circumstances. In yours, yes. But not all.


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## afalcon@dhcla.com (May 19, 2015)

3/25 I would code 99223-25 then 43235 for 456.1
3/26 I would code 45380 then 43244.


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