Gastroenterology Coding Alert

Learn when you should -- and shouldn't -- use modifier 59

When your gastroenterologist performs more than one upper gastrointestinal endoscopy on the same patient during the same encounter, you should look for biopsy details and such procedures as polyp removal and band ligation in the op notes. Pick Out Your Payer Guidelines When reporting multiple endoscopies from the 43235 code family (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), make sure you get the code order right. Then you must know each of your payers- reporting guidelines.
 
Why? Although an upper GI endoscopy takes a lot of time and expertise, each additional maneuver or therapy during the procedure requires more of each. If you don't report these encounters correctly, the claim may not secure your practice rightful payment for the encounter. Get to Know the Most Frequent Multiscope Code There are many upper GI endoscopy combos that your physician can perform within the 43235 family, experts say. And most of those code combos include 43239 (... with biopsy, single or multiple).

Scenario 1: The gastroenterologist treats a patient for bleeding gastric ulcers and also takes a biopsy in a separate upper GI area.
 
When this occurs, you should:

- report the biopsy with 43239.

- use 43255 (... with control of bleeding, any method) to report the ulcer treatment.

- attach modifier 59 (Distinct procedural service) to 43255 to show that the biopsy and ulcer care occurred at different sites. 
 
Don't miss this: When your gastroenterologist performs 43255 and 43239 together, you have to place modifier 59 on 43255 if your claim shows that the bleeding is separate from the biopsy and not caused by the biopsy. The reason is that the National Correct Coding Initiative bundles this code pair.

-I-m surprised to see that you-re supposed to use modifier 59 on 43255 because I would-ve added the modifier to the other code,- says Sara Fritsinger, CPC-H, CMC, CMIS, billing specialist at the Central Wyoming Outpatient Surgery Center LLC in Casper.

You must append modifier 59 to the column 2 code to indicate to the payer that the billed procedures are distinct and separately identifiable, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. Code Combos Can Vary Check out this other common scenario.

Scenario 2: A patient with dysphagia and reflux symptoms reports to your office. The gastroenterologist dilates the esophagus with a balloon catheter and biopsies a separate area where he suspects Barrett's esophagus.

On the claim, you should:

- report 43249 (... with balloon dilation of esophagus [less than 30-mm diameter]) for the dilation.

- attach [...]