Gastroenterology Coding Alert

When a patient is having several endoscopic procedures on the same day, the gastroenterologist must determine how to charge. For example, how would you code a colonoscopy done with polypectomy, and a biopsy done in a different site from the polyp removal? We talked to four practices for answers.

1. Do not use modifier -51. This is one of the biggest mistakes made by gastroenterology coders, because if you use it, it will reduce your fees unnecessarily, explains Susan Callaway-Stradley, CPC, senior consultant for the Medical Group, Elliott, Davis & Co. in Augusta, GA. If youre doing two endoscopies from the same family, you would never use a -51 modifier, she says. That would mean you would get an extra 50 percent taken off. Lets say youre doing a dilation (43249) and a biopsy (43239). These are both in the same family, both being done under endoscopy. Medicare pays for them in this way: full price for the first procedure, and the second procedure would be paid by subtracting the cost of the base procedure. In this case, the base procedure is the upper gastrointestinal endoscopy (43235). In Callaway-Stradleys state, Medicare pays $191 for 43249 (which you would call the first procedure), $178 for the 43239 (the second procedure), and $158 for 43235 (the base procedure). The payment for 43249 and 43239, therefore, would be $191, plus $20 ($178 minus $158), or $211. Theyre not going to pay you twice to put the scope down, so that is the rationale behind the subtraction. "If you add modifier -51, Medicare will gladly reduce the $20 to $10," says Callaway-Stradley. Many practices lose money by this inappropriate use of modifier -51.

2. The modifier -59 route...may be necessary. While modifier -59 is the modifier of last resort, to be used only when other modifiers are not appropriate, it may be needed to get reimbursed for the biopsy, says Jean Mead, billing manager for Gastroenterology Associates, a five-gastroenterologist practice in Mineola, NY. Modifier -59 is for a distinct procedural service, and the biopsy, says Mead, would qualify if it were done in a different site from the other procedure (see definition in box on this page). Recently, Medicare has stopped paying for a biopsy done at a different site during a colonoscopy with a polypectomy, she says. So now the practice is using modifier -59 on the biopsy ( CPT 45380 ). We get back half of the biopsy fee, says Mead. As for commercial payers, it is much more difficult to get paid for the biopsy, no matter what modifier you use, she adds. But sometimes it does help to send an operative note.

Modifier -59: Distinct Procedural Service Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier -59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate it should be used rather than modifier -59. Source: CPT 1999

3. A different diagnosis. Margaret Stewart, billing supervisor for the Metropolitan Gastroenterology Group, a nine-gastroenterologist practice in Washington, DC, agrees with using modifier -59 on the biopsy (45380). But its not enough just to use the modifier, says Stewartyou need to have two separate diagnoses. You need one diagnosis for the colonoscopy done with the polyp removal, and another diagnosis for the biopsy, she explains. For the colonoscopy and polypectomy, you could use a diagnosis of 211.3 (benign neoplasm of the colon), and for the biopsy, you could use 562.10 (diverticulosis of colon), assuming that is why you biopsied.

Dont wait for the pathology report to come back before filling in the diagnosis, she relates. However, Stewart does wait for the pathology report before filing the claim. And you should definitely send the op notes (and pathology report) with the claims, she adds.

4. The phone review. Because of recent problems in getting paid for a biopsy when its performed in addition to a colonoscopy/polyp removal, Peg Hopwood, supervisor of patient accounts for Rockford Gastroenterology, a nine-gastroenterologist practice in Rockford, IL, believes in doing phone reviews right away. As soon as we get an EOB with the biopsy denied, we try to do a phone review, says Hopwood. We state our case, explaining that the biopsy was in a different site, she explains. If they want a report we can send that. But usually this clears it up right away. The biggest benefit of a phone review is speedit works faster than a written review, Hopwood stresses.