Gastroenterology Coding Alert

Let these facts help guide your modifier usage.

If the modifier 59 coding rules seem to get more confusing the more charts you code, CMS has stepped in to help with an update to its advice. Gastroenterology Coding Alert checked out the changes and picked out the most important facts – read on to find out whether this impacts your practice.

Background: On December 28, CMS issued an update to Transmittal 4188, with an implementation date of January 30, 2019. As part of its clarifi­cation to the National Correct Coding Initiative (NCCI) section of the Medicare Claims Processing Manual, the transmittal spells out the requirements for when modifier 59 (Distinct procedural service) is appropriate. CMS has published such information elsewhere, but the agency has now taken the step of adding this verbiage to chapter 23 of the Manual.

A summary of the changes – along with GI-specific examples – are below.

Check These Examples of When You Can – And Can’t -- Use Modifier 59

Example 1: “Modifier 59 is used appropriately for different anatomic sites during the same encounter only when procedures are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ,” the transmittal states.

GI-Specific Scenario: The gastroenterologist cauterizes a bleeding ulcer in the stomach and takes a biopsy from the esophagus. As these services take place in two separate sites, then the 59 modifier would be appropriate to indicate separate noncontiguous procedures:

• 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple)
• 43255-59 (Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method)

Example 2: “Modifier 59 is used appropriately when the procedures are performed in different encounters on the same day,” the transmittal says.

GI-Specific Scenario: The gastroenterologist sees a patient for an ERCP but discontinues it halfway through because the anatomy of the biliary tree makes cannulation impossible. The patient is sent to radiology, where a percutaneous transhepatic biliary stent is placed. Later that day, the physician performs an ERCP with sphinc­terotomy and stent placement, then removes the PTC catheter. The modifier 59 would be used since the visits were for separate encounters on the same date, but you’d also append modifier 52 (Reduced services) to 43274 to indicate that the service was not performed to completion:

• 43274-52 (Endoscopic retrograde cholangiopancreatography (ERCP); with placement of endoscopic stent into biliary or pancreatic duct, including pre- and post-dilation and guide wire ...)
• 43262-59 (Endoscopic retrograde cholangiopancreatography (ERCP); with sphincterotomy/papillotomy)

Example 3: “Modifier 59 is used inappropriately if the basis for its use is that the narrative description of the two codes is different,” the transmittal says.

GI-Specific Scenario: A patient presents for a colonoscopy. The physician collects a specimen via brushing and also biopsies that same lesion. The physician reports the following codes:

• 45380 (Colonoscopy, flexible; with biopsy, single or multiple)
• 45378-59 (Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

In this case, you cannot append modifier 59 to 45378 – in fact, you can’t report 45378 at all, even though the descriptors are different on the two codes. The reality is that if you perform a more extensive procedure, you should report only that. Here, 45380 is the more extensive procedure, so in this situation, that’s the only code you should bill.

Keep in mind: In all of the above examples, the transmittal states, “Use of modifier 59 does not require a different diagnosis for each HCPCS/CPT^® coded procedure. Conversely, different diagnoses are not adequate criteria for use of modifier 59.”

Modifier 59 Isn’t Automatically the Best Choice

Although CMS has clarified its regulations for when you can report modifier 59 (Distinct procedural service), that doesn’t mean you always should append it when reporting codes together that are typically bundled under the Correct Coding Initiative.

In some cases, other modifiers may be more appropriate, and in those situations, you should report these modifiers instead of 59. Alternative modifiers may include the following, among others, depending on the circumstances – but always check with your payer to clarify which modifiers they accept, and what their preferences might be:

• Modifier XE -- Separate encounter
• Modifier XS -- Separate structure
• Modifier XP -- Separate practitioner
• Modifier XU -- Unusual Non-Overlapping Service
• 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 orother service
• Modifier LT-- Left side
• Modifier RT-- Right side
• Modifier 57 -- Decision for surgery 

Therefore, you need not document different diagnosis codes to justify the use of modifier 59 – and you shouldn’t assume you can separate NCCI edits just because you have separate ICD-10 codes.

Resource: To read CMS Transmittal 4188, visit https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R4188CP.pdf.