Gastroenterology Coding Alert

Did you know you can report more than a single CPT code on your endoscopy claims? If you think more than one code means you're double-dipping, you could be missing out on reimbursement your gastroenterologist deserves.

Bottom line: Endoscopy rules allow multiple billing of certain endoscopic procedures. "If your physician performs two or more distinct procedures at the same session in a different site, you can separately report both procedures with the appropriate modifier," says Edwin Elson, CPC, practice manager at Pediatric Gastroenterology and Nutrition of Tampa Bay in Florida.

Try your hand at the following scenario, and follow three steps to create a picture- perfect claim.

Scenario: Your gastroenterologist performs an EGD with biopsy of the stomach as well as an EGD involving the control of a bleeding ulcer in the duodenum. How should you report this? What should you expect for reimbursement?

First, you should isolate the codes you would report in this situation. Both codes are in 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]).

For the EGD with biopsy of the stomach, you would report 43239 (... with biopsy, single or multiple). "You should report this code only once, regardless of how many biopsies your physician performed," Elson says.

For the EGD involving the bleeding ulcer in the duodenum, you would report 43255 (... with control of bleeding, any method).

Why does this matter? Because both of these codes (43239 and 43255) include the value of a diagnostic EGD (43235), you will have to apply the special rules for endoscopy.

Next, you should refer to the Medicare fee schedule to determine the relative value units (RVUs) of the diagnostic EGD or base code. Code 43235 carries 3.76 RVUs (or $143, based on the 2008 conversion factor of 38.0870) if your gastroenterologist performed this in a facility.

Now look to your two EGD codes in the scenario. Code 43255 has 7.35 RVUs (or $279), and 43239 has 4.46 RVUs (or $170). This means you should report 43255 first. Rationale: Your carrier will reimburse the higher valued code (43255) at 100 percent its value.

What happens to the lesser code: As for the lesser valued code (43239), you can calculate your reimbursement this way. Your carrier will reimburse the full RVU, minus the price of the diagnostic service (43235). In other words, you should take 4.46 RVUs (the cost of 43239) and subtract 3.76 RVUs (the cost of 43235). That equals 0.70 RVUs and is the amount you should expect for the second procedure (around $27).

Note: You should not include 43235 anywhere on your claim.

Finally, gather your codes. You know you should report 43255 first and 43239 second from Step 2, but that's not the end of the story. You need to apply a modifier 59 (Distinct procedural service).

Why? Modifier 59 on the first procedure tells the carrier that when your gastroenterologist performed the control-of-bleeding EGD, this took place at a different site than the biopsy-of-the-stomach EGD. If you do not apply this modifier, the carrier will bundle the codes, thinking that you are trying to report a biopsy-of-the-stomach EGD as well as the control of bleeding caused by the biopsy procedure. If that's the case, carriers consider the control of bleeding bundled and reimburse you only for 43239.

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-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.

In other words, if you leave off modifier 59 on 43255, you will receive only 4.46 RVUS of reimbursement, rather than the 8.05 RVUs this claim actually deserves. Based on the 2008 conversion factor of 38.0870, that's a difference of $137 for each miscoded claim.

Therefore, your claim should look like this:

• 43255-59

• 43239.

Good advice: Don't forget to look at the comment box on the CMS-1500 form. In that comment box, you should enter "duodenum" next to 43255 and "stomach" next to 43239 to reinforce your separate-site claims.

Also, be sure the op note describes both procedures and techniques that the physician used, Elson says.