Gastroenterology Coding Alert

Coders can use control-of-bleeding codes for situations other than when a gastroenterologist uses a cautery, such as a heater probe, bi-cap probe or laser. The codes are defined by CPT to include any method used to control bleeding, which includes injections of epinephrine and sclerosing agents, as well as band ligation techniques.

Epinephrine injections, for example, can be used instead of cauterization to control bleeding of arteriovenous malformations (AVMs), ulcers or diverticula. The phrase any method in the CPT definition for control of bleeding includes injections as well as cauterization, says Pat Stout, CMT, CPC, an independent gastroenterology coding consultant in Knoxville, Tenn. If a gastroenterologist injects epinephrine into a bleeding duodenal ulcer, report 43255 (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]; with control of bleeding, any method) for the endoscopic injection of the epinephrine.

Report an epinephrine injection to control bleeding in combination with a polypectomy or biopsy, as long as the polyp was in a different location than where the control of bleeding was performed. For example, if a biopsy is taken from a polyp found in the stomach and epinephrine is injected into a bleeding duodenal ulcer, report both procedures.

When to Use Modifier -59

In the above situation, 43239 (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]; with biopsy, single or multiple) should be used to report the biopsy. Use 43255 to report the control of bleeding, with modifier -59 (distinct procedural service) attached. Even though 43255 with a 2001 transitioned facility relative value unit (RVU) of 7.23 vs. 4.59 for 43239 is the higher-valued procedure, it is the code that is normally denied by a payer because it is bundled into the biopsy code.

You always add modifier -59 to the code that would otherwise be denied, Stout explains. Its the control-of-bleeding procedure that is usually bundled into the other endoscopic procedures and not the other way around, so that would be the procedure that Medicare and other payers would tend to deny.

Because these codes have the same base endoscopic code (43235, 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]), the multiple endoscopy payment rule applies. The control-of-bleeding procedure should be reimbursed at 100 percent of its allowed fee because it is the higher-valued procedure. Payment for the biopsy code will be the difference between it and its base endoscopic code.

Gastroenterologists will not be reimbursed separately for the epinephrine injection. If the procedure is performed in a hospital, you can bill for the epinephrine. But if the procedure is performed in an ambulatory service center, the epinephrine is considered to be included in the facility fee, Stout explains. Gastroenterologists should not separately report the drug.

Coding With Esophageal and Gastric Varices

Another situation when the control-of-bleeding codes may be used is with bleeding esophageal and gastric varices, which are enlarged blood vessels. Gastroenterologists commonly use two methods for treating these: endoscopic sclerotherapy and band ligation. With endoscopic sclerotherapy, an endoscope with a needle attached is passed through the esophagus and the patient is injected with a sclerosing agent that causes the varices to clot and stop bleeding, Stout explains. With band ligation, an endoscope with a ligator attached is used to wrap bands around the varices and stop the flow of blood. If the varices are bleeding when either treatment is performed, use 43255 to report the procedures, Stout recommends.

Varices are not always bleeding when treatment is being done, however, and the gastroenterologist may perform a prophylactic sclerotherapy or band ligation to prevent bleeding. In addition, the gastroenterologist may perform followup sclerotherapy or band ligation when the varices are no longer bleeding, according to Freda Arlow, MD, FACG, a gastroenterologist at the Henry Ford Health System in West Bloomfield, Mich., and a member of the CPT Editorial Advisory Committee.

Use 43243 (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]; with injection sclerosis of esophageal and/or gastric varices) to report the injection of sclerosis treatment into non-bleeding varices. The 2001 transitioned facility RVU for this procedure is 7.59.

Use 43244 (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]; with band ligation of esophageal and/or gastric varices) to report the band ligation of non-bleeding varices. The 2001 transitioned facility RVU for this procedure is 7.19.

RVUs Are Inconsistent

One of the problems with using these codes is that there is no consistency in the relationship of the RVUs for these procedures. This is tricky because the RVU for the band ligation code (43244) is slightly lower than the RVU for the control-of-bleeding code (43255), Arlow explains. And the sclerotherapy code 43243 is valued a little higher than the RVU for the control-of-bleeding procedure.

However, Arlow believes that the most consistent and appropriate approach is to report the control-of-bleeding code when the varices are actively bleeding and to report either the sclerotherapy or band ligation codes when they are not. Although gastroenterologists want to report the highest RVU for what was done, they also need to report the most specific description, she explains.

While code 43255 is the only control-of-bleeding code cited as an example in this article, there are control-of-bleeding codes for all sections of the gastrointestinal tract.

Whether the physician is performing esophagoscopy with control of bleeding (43227), a colonoscopy with control of bleeding (45382), an anoscopy with control of bleeding (46614) and so on, all of these code descriptions contain the phrase any method and can be used to report cauterizations, injections and band ligations.