Gastroenterology Coding Alert

Don't let documentation be your downfall when you code multiple EGDs.

Thanks to the frequent use of modifier -59 (Distinct procedural service) to unbundle and report multiple endoscopies from the same family, it is imperative that you have sufficient, clear documentation of each service for separate reimbursement. Modifier -59 may be a powerful tool to increase payments, but without the required documentation, you could be looking at messy audits and even fraud allegations.

Here are some things to keep in mind when submitting claims for multiple EGDs when modifier -59 is a factor:

Be prepared if the insurer requests additional documentation. Don't be surprised if you are asked to supply more information supporting the use of modifier -59. If the reason for the use of modifier -59 is that the procedures were performed at separate locations, submit documentation that clearly indicates the different sites. Or, if an EGD was performed but esophageal or stomach lesions were treated, note the reason for extending the scope past the pylorus in the "Findings" section of the operative report.

Note in the patient's chart the time and date each service was rendered. One circumstance that merits the use of modifier -59 is if the services were rendered at different sessions or patient encounters. It is imperative that the nurses'reports and the patients'charts have documentation of the time and date of each service if the reason you have chosen modifier -59 is that the services were performed at different encounters. With the right documentation, you will be able to convey the different encounters to the carrier if a diagnostic EGD is performed in the morning and an EGD with biopsy is performed in the afternoon.

Document the use of different methods. If a gastroenterologist reports the removal of multiple lesions with an EGD, you shouldn't necessarily get paid for more than one lesion removal. But if each lesion was removed using a different technique, it's another story. For example, if a gastroenterologist removes two lesions in the esophagus by hot biopsy forceps, you can report 43250 only once. However, if the gastroenterologist removes one lesion by hot biopsy forceps and another lesion by snare technique, you can report 43250 and 43251-59 but only if the two distinct methods of lesion removal are clearly documented.

Link different diagnosis codes to each CPT code reported when applicable. Different diagnosis codes will help convey to the carrier the medical necessity behind performing the two procedures together and billing them separately.

Append modifier -59 last. If you are using modifier -59 in addition to other surgical modifiers such as -51, -58 or -78, append modifier -59 last.