Gastroenterology Coding Alert

At times, critical care may best describe the physician's services

Dealing with excessive blood loss is one reason a GI physician might justify using modifier 22, but in many cases you may be better off simply reporting a separate code--or even critical care--for control of bleeding.

Endoscopy With Injection May Warrant 43255

If the gastroenterologist uses epinephrine injection for control of bleeding during an upper GI endoscopy, you might call on 43255 (Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; with control of bleeding, any method)--in addition to the code for the primary procedure--to describe the physician's effort.

Example: The doctor injects epinephrine into a duodenal ulcer to control active bleeding during endoscopy with biopsy (43239, -with biopsy, single or multiple).
 
In this case, if the control of bleeding adds significant physician effort, you may be tempted to report 43239 with modifier 22 (Unusual procedural services) appended.

Better way: Instead of reporting 43239-22 and struggling to provide all the additional documentation that the payer will require for a modifier 22 claim, you can accurately describe this session by reporting 43239 for the biopsy and 43255 for the control of bleeding, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the CPT advisory panel. Code 43255 accurately describes control of bleeding by -any method,- including injection.

Important: You cannot report control of bleeding if the gastroenterologist causes the bleeding, says Linda Martien, CPC, CPC-H, a member of the AAPC's National Advisory Board. You should call on control-of-bleeding codes only -when treatment is required to control bleeding that occurs spontaneously, or as a result of traumatic injury (noniatrogenic), and not as a result of another type of operative intervention,- according to the AMA-s Principles of CPT Coding .

Unstable Patients May Warrant Critical Care

In some cases, the patient's condition might necessitate critical care (99291, 99292) instead of a procedure code with modifier 22. Weinstein cites a situation in which the physician plans to perform an upper GI endoscopy, but the patient has gastrointestinal bleeding so severe that the physician must suspend the endoscopy and spend 40 minutes lavaging blood from the gastro-intestinal tract before continuing.

In this situation, Weinstein would report critical care  99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes).

Don't overdo it: You shouldn't report a critical care code for a normal control-of-bleeding situation or if the physician causes the bleeding. In this example, however, the patient meets the definition of being critically ill because there could be a potentially life-threatening deterioration in the patient's condition due to the severity of the bleeding, Weinstein says.

Learn more: For complete information on critical care services, look to an upcoming edition of Gastroenterology Coding Alert.