Gastroenterology Coding Alert

Hint: Modifier SG could be your friend.

Suppose you bill Medicare when your gastroenterologist performs an EGD, colonoscopy, or other procedure in an ASC. Do you know when the “same-day global” rule applies? Do you know when to apply modifier SG or discontinued modifiers?  

Although CMS has tweaked ASC coding rules in the past, some have remained the same. The following three ASC tips can help you button up your ASC coding.

1. Remember the “Same-Day Global” Rule

Every procedure billed by the ASC has a “same-day” global period. This makes sense because the ASC is not reporting physician work services -- only facility fees. This applies to the coder working for the ASC, but not the physician who performed the service.

For instance, if a patient experiences postoperative bleeding and the physician must return the patient to the ASC for control of bleeding on the same day, both the physician’s coder and the ASC’s coder should report the appropriate control-of-bleeding code appended with modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) because the procedure occurred within the -same-day- global period for the ASC.

Takeaway: The ASC coder should follow the “same-day” global rule, but the physician’s coder should follow standard global period rules from the fee schedule, experts say.

2. Properly Append Modifier SG

When the ASC coder bills Medicare for any service performed in the ASC, she must list modifier SG (Ambulatory surgical center [ASC] facility service) as the first modifier on the claim. And remember to append modifier SG to every code listed on the claim, not just the first code.

For example, the gastroenterologist performs an EGD with biopsy (43239). The ASC coder should report 43239-SG and the gastroenterology coder will report 43239 alone.

3. Discontinued Coding Modifiers May Differ

ASC coders may occasionally use modifier 52 (Reduced services) but won’t use modifier 53 (Discontinued procedure). Instead, insurers usually require ASC coders to call on modifiers 73 (Discontinued out-patient hospital/Ambulatory surgery center [ASC] procedure prior to the administration of anesthesia) or 74 (Discontinued out-patient hospital/Ambulatory surgery center [ASC] procedure after administration of anesthesia), as appropriate.

For example: A gastroenterologist is performing a colonoscopy with lesion removal (45380). But after the procedure has commenced, the patient develops significant cardiac arrhythmia. Although the anesthe­siologist works to control the patient’s vital signs, the medical team decides to discontinue the procedure. The gastroenterology coder should report 45380 with modifier 52 or 53, depending on whether:

• the physician finished part of the procedure but not the whole thing OR
• if the physician put the scope into the colon but then halted the procedure

Plus, the ASC coder should report 45380-SG-74.

Note:  Medicare keeps the full list of allowable ASC procedures on its website, according to the year that the physician performed the service. Visit the CMS site www.cms.hhs.gov/ASCPayment/ for the full list of ASC-allowed procedures.