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 ICD-9 codes 787.2 (Dysphagia) and 530.81 (Esophageal reflux) to 43249 to prove medical necessity for the dilation.

- report 43239 for the biopsy.

If your gastroenterologist finds Barrett's esophagus and documents it as definitive, you-ll attach 530.85 (Barrett's esophagus) to 43239 to prove medical necessity for the biopsy.

Although you won't find an NCCI edit for this scenario, you may still want to append modifier 59 to 43239 to show that the biopsy was separate from the dilation. Some commercial carriers still bundle the codes, so check with your carrier.

Careful With Modifier 59

Whether you should use modifiers on your multiple- endoscopy claim will depend on the situation. You may be tempted to append modifier 59 on each multiple-scope claim without even thinking about it. But if you-re not sure that every payer wants modifier 59 on a multiple-EGD claim, you cannot be sure that the claim will be clean.

Watch out: If the scopes happen in the same code family, your code combination may be subject to National Correct Coding Initiative edits.

Scenario 3: The gastroenterologist performs an upper GI endoscopy with biopsy and a guidewire esophageal dilation during the same session. The CPT codes for this example are always the same.

On the claim, regardless of payer, you should:

- report 43248 (... with insertion of guidewire followed by dilation of esophagus over guidewire) for the dilation.

- bill 43239 for the biopsy.

The modifiers you attach on this claim, however, will depend on your payer. -[For us], you don't need any modifiers on this combination,- Fritsinger says. -You have to really watch your edits when you-re reporting EGD claims.-

Best advice: Don't generalize. Take the time to learn each payer's specific rules on reporting multiple upper GI endoscopies. Some payers will want you to use a modifier combination, while others might not want to see any modifiers at all. You should know all payer guidelines before a multiple upper GI scope claim hits your desk.