Gastroenterology Coding Alert

Nowadays, whenever the Correct Coding Initiative (CCI) comes up, coders automatically think "modifier 59."

But the "unbundler" is often misunderstood -- and misused.

According to the Medicare Claims Processing Manual and the CPT Manual, modifier 59 (Distinct procedural service) indicates that a provider performed a distinct procedure or service for a beneficiary on the same day as another procedure or service. It may represent a:

• Different session,

• Different procedure or surgery,

• Different anatomical site or organ system,

• Separate incision or excision,

• Separate lesion, or

• Separate injury (or area of injury in extensive injuries).

First and foremost, your documentation must be correct. Modifier 59 popped up on the Department of Health and Human Services Office of Inspector General's work plan for 2005. "It wasn't just the modifier being used incorrectly, it was that the documentation didn't support the use of any modifier," says Vicky Varley O'Neil, CPC, CCS-P, owner of The Hazlett Group, a practice management consulting firm based in St. Louis.

When procedures are performed together that are similar, or performed on the same organ but are qualified by an increased level of complexity, the less extensive procedure is included in the more extensive procedure.

Because Medicare's physician fee schedule translates "more extensive" into higher relative value units, the "less extensive" procedure is often understood as the procedure of lower value.

Since many of a gastroenterologist's procedures are endoscopies, let's focus on how they're bundled. Endoscopies are categorized into "families" that share a base diagnostic code, which you can locate in the National Physician Fee Schedule spreadsheet. Find the endoscopy code you want in column A, and then scan across to column AD, which is labeled "Endo Base." When you code any two procedures that share an "Endo Base" code, Medicare will bundle them. Download the fee schedule at www.cms.hhs.gov/PhysicianFeeSched.

However, you may report more than one surgical endoscopy as long as your gastroenterologist used a different technique and a different site. When you unbundle these procedures, you append the modifier to the less extensive procedure.

Example: While your physician performs an EGD with injection (43236, Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; with directed submucosal injection[s], any substance), she encounters a stricture in the gastric valve that would prevent her from viewing the duodenum. She dilates the stricture (43248, ... with insertion of guide wire followed by dilation of esophagus over guide wire) and completes the examination. Because the EGD with dilation isa more extensive procedure than the EGD with injection, you would code 43248, 43236-59.

You should first check the latest CCI edits to see whether they are bundled, then see whether you may override that edit with modifier 59. If so, which procedure is bundled into which?

For instance, CCI lists 44364 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) as mutually exclusive of 44365 (... with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery). The payer would not expect that the gastroenterologist would remove the same polyp, for instance, using both a snare and hot biopsy forceps.

The edit that bundles 44364 to 44365 includes a 1 modifier indicator. So if the snare removal occurs at a different location than the removal with hot forceps, you may report the services independently (note, however, that medical necessity, as explained in the documentation, would have to justify why the physician required two different methods to remove the polyps in distinct areas).

If a CCI edit includes a 0 modifier indicator, you may never report the two procedures together.

Your documentation must demonstrate that the service was distinct from others performed on the same day, says O'Neil. She offers a list of tips:

• Document separate lesion treatments or sessions

• Document sequential procedures

• Keep track of time (when were the separate procedures started and finished)

• Separate procedure notes may be appropriate.

'Separate procedure': All procedures identified as "separate procedures" by CPT will be subject to extensive bundles by CCI, says Barbara J. Cobuzzi, MBA, CPC,CPC-H, CPC-P, CENTC, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J. That includes codes like 44376 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) and 91000 (Esophageal intubation and collection of washings for cytology, including preparation of specimens [separate procedure]).