Gastroenterology Coding Alert

Find out what bundles you can bill together using modifier 59.

Key changes to the gastroenterology practice entail a veto on proctosigmoidoscopy and therapeutic anoscopy procedures, among other modifications. Check out what you should do post July 1 with the following tips.

Backround: The latest Correct Coding Initiative (CCI) edits took effect on July 1, 2011, and carries 2,343 new edit pairs and 224 deletions --" relatively fewer than previous edits. Most edits come from the musculoskeletal code range. However, bundles also affect the Surgery/Digestive System section of the CPT® manual.

Don't Ignore Your 45300 Bundles

CCI assigns a modifier indicator of "0," and enforces a series of edits for:

• 46615 (Anoscopy; with ablation of tumor[s], polyp[s], or other lesion[s] not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique) and 45300 (Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure])
• 46614 (...with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]) and 45300
• 46612 (...with removal of multiple tumors, polyps, or other lesions by hot biopsy forceps, bipolar cautery or snare technique) and 45300
• 46611 (...with removal of single tumor, polyp, or other lesion by snare technique) and 45300
• 46610 (...with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery) and 45300
• 46608 (...with removal of foreign body) and 45300
• 46606 (...with biopsy, single or multiple) and 45300
• 46604 (...with dilation [e.g., balloon, guide wire, bougie]) and 45300.

"These changes basically say that the code for therapeutic anoscopy procedures cannot be used with the base code for proctosigmoidoscopy (rigid sigmoidoscopy). The correct code would be from the family of proctosigmoidoscopy codes 453xx," says Michael Weinstein,

MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT® Advisory Panel. You cannot use these codes together under any circumstances and if you do, the higher value code will be denied.

Similarly, another series of edits involving 45300 shows up in CCI Edits 17.2 as follows:

• 46220 (Excision of single external papilla or tag, anus) and 45300
• 46080 (Sphincterotomy, anal, division of sphincter [separate procedure]) and 45300
• 46040 (Incision and drainage of ischiorectal and/or perirectal abscess [separate procedure]) and 45300
• 45915 (Removal of fecal impaction or foreign body [separate procedure] under anesthesia) and 45300
• 45910 (Dilation of rectal stricture [separate procedure] under anesthesia other than local) and 45300
• 45905 (Dilation of anal sphincter [separate procedure] under anesthesia other than local) and 45300
• 45900 (Reduction of procidentia [separate procedure] under anesthesia) and 45300.

These edits say that the proctosigmoidoscopy code (in column 2) is included in the column 1 code and cannot be used together under any circumstances. Again, if you used these codes together in your claim, the payer would likely deny the higher value code.

Hemorrhoid Banding Gets Its Share of Edits

CCI Edits 17.2 has marked another series of bundles with a modifier indicator "1," meaning you may report them under appropriate clinical circumstances with an appropriate modifier (such as 59, Distinct procedural service). They are:

• 46221 (Hemorrhoidectomy, internal, by rubber band ligation[s]) and 45300
• 46221 and 45303 (Proctosigmoidoscopy, rigid; diagnostic, with dilation [e.g., balloon, guide wire, bougie])
• 46221 and 45317 (...with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator])
• 46221 and 45330 (Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure])
• 46221 and 45334 (...with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator])
• 46221 and 45340 (...with dilation by balloon, 1 or more strictures)
• 46221 and 46614.

"These code edits suggest that hemorrhoid banding (column 1 code) is done on the same area as the therapy described in the column 2 code if both codes appear on the same claim. However, you can use these codes together if the reason is a separate site. In that case, you would need to append modifier 59, explains Weinstein.

E/M With AWV: CCI Edits 17.2 Make The Use Of Modifier 25 Official

Lastly, you should look out for a bunch of edits referring to the Medicare Annual Wellness Visits (G0438, Annual wellness visit; includes a personalized prevention plan of service [pps], initial visit; G0439, Annual wellness visit, includes apersonalized prevention plan of service [pps], subsequent visit) and other E/M visit codes. (See http://www.trailblazerhealth.com/Publications/Job%20Aid/AnnualWellnessVisit.pdf for the details.)

When it comes to reporting AWVs with E/M visits, CCI Edits 17.2 allow the use of a modifier to the E/M code if you have a medically necessary ground to separate the bundles. This would only apply to gastroenterologists who also do routine internal medicine care of Medicare patients.