Gastroenterology Coding Alert

Forget about modifier 22 or you'll be stuck in old school.

Modifier 22 may not be the ally you're looking for when coding for excessive blood loss. The answer may lie on more appropriate CPTs such as 43255 and critical care codes. Learn from these two scenarios.

Consider Endoscopy-With-Injection as Option

Scenario 1: The doctor injects epinephrine into a duodenal ulcer to control active bleeding during endoscopy with biopsy (43239, Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple).

Code it: In the past, you may opt to use 43239 appended with modifier 22 (Increased procedural services) if the physician required significant effort to control the patient's bleeding.

This option, however, would require you to submit additional paper documentation to support your modifier 22 claim.Instead of submitting yourself to potential hassles, you can accurately describe this session by reporting 43239 for the biopsy and 43255 (Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; with control of bleeding, any method) for the control of bleeding provided that the bleeding was not caused by the biopsy.

As evident from 43255's descriptor, this procedure describes control of bleeding by "any method," including injection.

Requirement: On your claim, you should append modifier 59 (Distinct procedural service) to 43255, and then report 43239. Omitting the modifier would give payers the impression that the biopsy (or physician) caused the bleeding and bundle 43255 into 43239.

Extraordinary Bleeding Calls for Critical Care Coding

Scenario 2: When the gastroenterologist is about to perform an upper GI endocscopy, the patient experiences gastrointestinal bleeding so severe that the physician must suspend the endoscopy and spend 40 minutes lavaging blood from the gastro-intestinal tract before continuing.

Code it: This time, the critical code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) is your best option.

Why? If the gastroenterologist caused the bleeding, you cannot bill for the control of bleeding procedure, says Chris Harvey, LPN, coder/charger for Visionary Enterprises Inc. in Indianapolis. You should call on control-of- bleeding codes only "when treatment is required to control bleeding that occurs spontaneously, or as a result of traumatic injury (noniatrogenic), and not as a result of another type of operative intervention," states CPT Assistant.

Remember, the time spent at the bedside performing services including lavage of gastric blood is not included in the performance of a subsequent endoscopic procedure and is not part of the E&M service that might be performed on the same day.

Just the same, you shouldn't report a critical care code carelessly for an excessive bleeding situation that is not out of the ordinary. Additional time for emergency bedside services less than 30 minutes doesn't count as billable critical care service. For prolonged critical care services the physician should specifically note the amount of time in his notes.