Gastroenterology Coding Alert

In the September 1999 Gastroenterology Coding Alert, the article Correct Coding for Multiple Endoscopic Procedures on page 4 advocated use of modifier -59 (distinct procedural service) when coding for a colonoscopy with polypectomy and a biopsy done at a different site or area than the polyp removal. In the October issue, the article Two Methods for Improving Reimbursements of Colonoscopies With Multiple Removal Techniques on page 9 addressed the use of modifier -51 (multiple procedures) when coding for a colonoscopy with polypectomy that used two different methods (hot biopsy forceps and the snare technique) to remove polyps in the colon.

Part of the confusion over what modifier to use comes from a failing to clearly explain the differences in the coding situations highlighted in these two articles. Whether the two procedures are performed in different areas of the colon or the same significantly can change how they are billed and reimbursed.

Modifier -59 should be used to designate separate procedures. An article on the use of the modifier in the July 1999 issue of the CPT Assistant states, This indicates that the procedure is not considered a component of another procedure, but a distinct, independent procedure, such as a:

- different session or patient encounter;
- different site or organ system;
- separate incision/excision;
- separate lesion; or
- treatment of a separate injury (or area of injury in extensive injuries).

Modifier -51 should be used to indicate multiple procedures. The same CPT Assistant article states that modifier -51 has four applications, namely to identify:

- multiple medical procedures performed at the same session by the same provider;
- multiple, related operative procedures performed at the same session by the same provider;
- operative procedures performed in combination at the same session, by the same provider, whether through the same or another incision or involving the same or different anatomy; and
- a combination of medical and operative procedures performed at the same session by the same provider.

Determining whether to use modifier -51 or -59 can be confusing if gastroenterologists try to commit a set of rules and situations to memory, says Pat Stout, CMT, CPC, an independent gastroenterology coding consultant. In her opinion, the best resource is the Correct Coding Initiative (CCI), which was adopted by Health Care Financing Administration (HCFA) to avoid payment of incorrectly coded claims.

If the CPT code for a medical procedure is listed in the CCI as being bundled into the code for another procedure, then Medicare will not reimburse for both codes, explains Stout. If these two procedures are performed in different sites of the gastrointestinal system, however, then modifier -59 can be attached to the procedure with the lower relative value unit (RVU). Medicare should reimburse fully for the first procedure and partially reimburse for the second procedure.

Stout uses the codes 45382 (colonoscopy with control of bleeding) and 45385 (colonoscopy by snare technique) as an example of two codes that are bundled together. The CCI bundles code 45382 into code 45385, meaning that the relative value units for control of bleeding already have been calculated into the relative value units of the polypectomy by snare technique.

Medicare will not reimburse for both of the two procedures, unless they are performed in different sites of the gastrointestinal system and modifier -59 is attached to the procedure with the lower relative unit value, which in this case is code 45385.

On the other hand, two codes that are not bundled together by CCI are 45384 (colonoscopy by hot biopsy forceps) and 45385. Therefore, these two procedures do not have to be performed in different parts of the gastrointestinal system to be billed together, according to Stout. Modifier -51 can be attached to the lesser valued, multiple procedure, which in this case is code 45384.

With regard to biopsies and polypectomies in the same area of the gastrointestinal system, the Correct Coding Initiative states, When, in the course of a procedure, a biopsy is obtained and subsequently excision, removal destruction or other elimination of the biopsied lesion is accomplished, a separate service cannot be reported for the biopsy as this represents part of the removal. Only the removal of the polyp should be billed.

When the biopsy and polypectomy are performed at different sites, however, the Correct Coding Initiative states that if a different polyp is identified, a biopsy may be reported separately with modifier -59, indicating a different service was performed or a different site biopsied. Therefore, the removal technique should be listed first because it has the higher RVU. Then the biopsy should be listed with modifier -59 attached.

Go to the Correct Coding Initiative, encourages Stout. If the codes are bundled together and the procedures were performed in different sites, you must use modifier -59 on the lesser valued procedure. If they are not bundled together, use modifier -51.

Occasionally, coders advocate the use of both modifiers at the same time. The American College of Gastroenterologists has stated that when a physician biopsies one polyp and then performs a polypectomy by snare technique of a another, both the biopsy and snare removal are billable. The second or lesser procedure should include the -51 modifier for multiple procedures and also the -59 modifier, showing this was a separate distinct procedure.

Because there is no hard-and-fast guideline on when to use which modifier, gastroenterologists should familiarize themselves with the policies of their local Medicare and private insurance payers.