Gastroenterology Coding Alert

Here's when you'll most often use this modifier in your gastro practice

When your gastroenterologist performs two procedures from the same endoscopic family, do you always report only one code? If you answered "yes," you may not be taking advantage of all the situations when you can use modifier 59.

Action 1: Use Mod 59 When Codes Are Close

Under certain circumstances, you may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. You'll use modifier 59 (Distinct procedural service) to identify procedures/services that you would not normally report together but are appropriate under the circumstances.

In general, coders append modifier 59 to procedure codes when the physician:

• sees a patient during a different session;

• treats a different site or organ system; or

• treats a separate lesion.

Hint: In gastro offices, this modifier "is not usually used during office visits," says Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Lawrenceville, Ga. "You'll generally use it when your gastroenterologist performs multiple procedures in the same endoscopic family at the same time."

Tackle These 2 Examples

Example 1: Let's say the gastroenterologist performs a colonoscopy with a cold biopsy and removes a separate polyp via snare technique.

You should:

• report 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s] or other lesion[s] by snare technique)

• attach modifier 59 to 45380 (... with biopsy, single or multiple). The modifier shows the carrier the MD treated two different sites.

"If you billed these codes without a modifier, the carrier could bundle 45380 into 45385," Parks says. That's a loss of about $250 in a facility setting, based on national averages.

Example 2: The gastroenterologist performs an upper gastrointestinal endoscopy (EGD) with balloon dilation of the esophageal stricture and an EGD with biopsy of a gastric ulcer.

You should these items:

• report 43249 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with balloon dilation of esophagus [less than 30 mm diameter])

• attach modifier 59 to 43239 ( ... with biopsy, single or multiple). The modifier shows the carrier the gastroenterologist performed two different procedures performed, even though they were both EGDs.

Action 2: Pay Attention to Code Order for CCI edits

Modifier 59 is an important Correct Coding Initiative (CCI)-associated modifier that is often used incorrectly. For CCI, its primary purpose is to indicate the physician performed two or more procedures at anatomical sites or different patient encounters.

Make sure you know which code needs modifier 59, or you could lose out on money. The modifier should always be placed on the component or Column 2 code. Otherwise, "the code carriers will deny due to Correct Coding Initiative (CCI) edits," Parks says.

By using modifier 59, the carrier will pay a claim where a procedure "would normally be considered an integral part of another procedure," says Annette Grady, CPC, CPC-H, CPC-P, CCS-P, compliance auditor at The Coding Network, and executive officer on the AAPC's National Advisory Board, in the audioconference entitled "Under the Magnifying Glass: A Closer Look at Mitigating Modifier Mishaps." Note: To order your transcript and audio conference materials, go to http://www.audioeducator.com.

Not sure about CCI? If you're stuck on whether you should bill codes with modifier 59, check the CCI edits. If the codes you are reporting have indicators of "1" next to them, this means you may be able to append an appropriate modifier to bypass the edit. If the code has an indicator of "0," you cannot bypass the edit. The CCI edits change quarterly, so be sure to keep abreast of all updates, Grady advises.

Time Saver: Increase your modifier 59 reimbursement rate by using it only when absolutely necessary -- many payers do not require the use of a modifier in multiple-procedure scenarios. Check with your individual payer to see if modifier 59 is necessary when reporting multiple-procedure claims.

However, don't be afraid to use modifier 59 if you have no recourse -- just make sure it is "the modifier of last resort."