Gastroenterology Coding Alert

You can sometimes collect for this service, if you know the rules.

Bleeding control can be a controversial topic among gastroenterology coders. While some believe this service is always billable, others err on the side of caution and never report it. The answer, however, lies somewhere in the middle.

Check out the following three frequently-asked questions about bleeding control and read on to find out when you can report this service and when you should simply include it in your other codes.

Scenario 1: Bleeding Control With EGD

Question: Our gastroenterologist performed an EGD with biopsy and bleeding control using thermal coagulation on a 67-year-old inpatient, along with a level three subsequent hospital visit. Medicare denied control of bleed (43255) but paid the EGD. Does Medicare cover/process codes in the order that they are listed on the claim?

Answer: Medicare will process the claim based on edits that the contractor has in place in its computer system. In your situation, you reported two codes that are bundled according to the Correct Coding Initiative (CCI), with the EGD being the "column 1" code. Therefore, no matter what order you used on your claim, Medicare payers (and other insurers that follow CCI) will pay you for the EGD and not the bleeding control unless you append a modifier.

Assuming that the physician decided to perform both the biopsy and the bleeding control for medically necessary reasons based on his examination (and any imaging/lab studies), you should report the esophagogastroduodenoscopy (EGD) with biopsy using 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple) as the primary code, because it is the column 1 code for this bundle, followed by 43255-59 (Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method; Distinct procedural service) for the bleeding control.

Caveat: Keep in mind that when bleeding occurs as a result of an endoscopic procedure, control of bleeding is not reported separately during the same operative session and Medicare will not pay for it. So, if your physician caused the bleeding when completing the biopsy, the bleeding control is not separately reportable.

In addition, you'll report 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient...) for the level three subsequent hospital visit. You need to attach modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service) to the E/M code to show that the E/M was a separately identifiable service from the EGD.  

Scenario 2: Can Injection Qualify You for 43255?

Question: The gastroenterologist attempted to perform an EGD with biopsy on a bleeding duodenal ulcer but was unable to perform the procedure because the ulcer was bleeding so severely. He injected epinephrine into a duodenal ulcer to control active bleeding during endoscopy with biopsy. We reported 43239-22 (Increased procedural services) but we were not paid extra for the modifier 22 addition. What did we do wrong?

Answer: Although the surgery was more complicated than a standard EGD due to the bleeding control, modifier 22 is not the right choice. Instead of reporting 43239-22 and struggling to provide all the additional documentation that the payer will require for a modifier 22 claim, you can accurately describe this session by reporting 43239 for the biopsy and 43255-59 for the control of bleeding. Although many coders shy away from reporting 43255 for bleeding control when it is achieved via injection, the descriptor for 43255 specifically says "any method," therefore making the injection method billable using this code. The insurer may still deny the charge due to addressing the same lesion, but this is the correct coding for this scenario, and the gastroenterologist can appeal if necessary.

Important point: Remember that the bleeding control doesn't have to be successful to report 43255, says Glenn  D.  Littenberg,  MD,  MACP,  FASGE,  AGAF, a gastroenterologist and former CPT® Editorial Panel member in Pasadena, California. "The code doesn't distinguish 'attempt' from 'successful hemostasis,'" he says.

Scenario 3: Is Critical Care an Option?

Question: The physician planned to perform an upper GI endoscopy, but the patient's gastrointestinal bleeding was so severe that the doctor had to suspend the procedure and instead spent 40 minutes trying to control bleeding because he felt that the patient was at risk of life threatening deterioration if the bleeding continued. Does 43255 cover this service?

Answer: Although the question doesn't include complete documentation, it's possible that in this case, the patient's condition might necessitate critical care (99291, Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes).

Don't overdo it:  You shouldn't report a critical care code for a normal control-of-bleeding situation or if the physician causes the bleeding. In this example, however, the patient may meet the definition of being critically ill due to the severity of the bleeding.

Keep in mind that only one physician may bill for critical care during any single time period, even if more than one physician is providing care. Therefore, if a critical care physician or hospitalist also attended to the patient, the GI specialist may not be able to bill the critical care code.