Coding Corner: Don't Skip the Extras With 43239

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Payer preferences and biopsy specifics can make a big difference in whether your facility receives appropriate payment for multiple same-day gastrointestinal endoscopies (EGDs). Take the time to determine the physician's - and the insurer's - exact treatment.
Pay Attention to Code Order
An upper gastrointestinal endoscopy takes a lot of time and expertise, and multiple endoscopies require even more of each. If you can't report these encounters correctly, you could be kissing $460 per patient goodbye.
When reporting multiple endoscopies from the 43235 "family" (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), make sure you get the code order right. Then, you need to know each payer's reporting guidelines, says Sherri Brasher, an insurance and billing specialist in Evansville, Ind. 
 
Know the Most Common Multi-EGD Code
There are many EGD combos that physicians perform within the 43235 family, but most of those code combos include CPT code 43239  (... with biopsy, single or multiple).
 
For example, if the physician treats a patient for bleeding gastric ulcers, she may also take a biopsy in a separate upper GI area. When this occurs, you should:
 
report the biopsy with 43239.

use 43255 (... with control of bleeding, any method) to report the ulcer treatment.

attach modifier -59 (Distinct procedural service) to 43255 to show that the biopsy and ulcer care occurred at different sites.
 
Code Combos Can Vary by Location
Physicians may perform EGDs on various anatomic sites at once - and you need to pay attention to which code, if any, requires modifier -59. "The most common [multiple-EGD] scenario I come across is an esophageal dilation done in conjunction with a biopsy at a different site," says Margaret Lamb, RHIT, CPC, of Great Falls Clinic in Great Falls, Mont.
 
Scenario: The physician dilates a patient's esophagus with a balloon catheter and biopsies a separate area where he suspects Barrett's esophagus. On the claim, Lamb says, you should:
 
report 43249 (... with balloon dilation of esophagus [less than 30 mm diameter]) for the dilation.

attach ICD-9 codes 787.2 (Dysphagia) and 530.81 (Esophageal reflux) to 43249 to prove medical necessity for the dilation.

report 43239 for the biopsy.

attach ICD-9 code 530.85 (Barrett's esophagus) to 43239 to prove medical necessity for the biopsy.

possibly, attach modifier -59 to 43239 to show that the biopsy was separate from the dilation. According to National Correct Coding Initiative (NCCI) edits version 11.1, codes 43249 and 43239 do not conflict, so modifier -59 may not be necessary. When in doubt as to whether a payer follows NCCI [...]

- Published on 2005-06-20