Gastroenterology Coding Alert

It was the biggest gastroenterology coding question when should modifier -51 (multiple procedures) be used on a claim for multiple endoscopic procedures, and when should modifier -59 (distinct procedural service) be used? Over the past two years, though, many gastroenterology practices have been phasing out modifier -51. Some have started billing modifier -59 in its place; others no longer use a modifier in those situations. While the wide variation in coding suggests there is no national consensus on modifier -51, some practices have reported improved reimbursement after they stopped coding it.

Although many coders discontinued modifier -51, there has been no official change in policy from CPT or Medicare regarding either modifier. Modifier -51 should be used in the following coding situations, according to the American Medical Association publication Principles of CPT Coding:

multiple medical procedures performed at the same session by the same provider   

multiple, related operative procedures performed at the same session by the  same provider
 

operative procedures performed in combination at the same session, by the same provider, whether through the same or another incision or involving the same or different anatomy
 

a combination of medical and operative procedures performed at the same session by the same provider.

The distinction between modifier -51 and modifier -59 has never been very clear. According to the AMA, modifier -59 is intended to clearly designate instances when distinct and separate services are provided to a patient on a single date of service. It is a default modifier "to be used if no more descriptive modifier is available."

Medicare still calls for modifier -51 when describing its two payment rules for multiple procedures. Medicare Carriers Manual sections 4826 and 15038 describe the payment rules and modifiers for multiple procedures:
 
1. Standard Payment Rule for Multiple Surgeries: If two or more procedures with different endoscopic base codes (unrelated endoscopic procedures) are reported on the same day, the procedures should be listed on the claim in descending order based on their relative value units (RVUs).
 
No modifiers are needed when unrelated endoscopic procedures are reported under the standard payment rule for multiple surgeries. For example, if a colonoscopy by snare technique (45385, 45378 [endoscopic base code]) is performed on the same day as an upper gastrointestinal endoscopy (43235 [endoscopic base code]), the standard payment rule applies and no modifier is needed.
 
2. Special Payment Rule for Multiple Endoscopies: If two or more endoscopic procedures with the same endoscopic base code are reported on the same day, the procedures should be listed on the claim in descending order based on their RVUs. Modifier -51 should be attached to the lower-valued procedure(s).
 
An example of multiple endoscopic procedures that are related, but not bundled, is 43265 (endoscopic retrograde cholangiopancreatography [ERCP] with lithotripsy), 43264 (ERCP with stone removal), and 43262 (ERCP with spincterotomy). The special payment rules apply because these codes have the same endoscopic base code, 43260 (diagnostic ERCP).
 
Modifier -59 has traditionally been used only when reporting multiple endoscopies that are bundled in the Correct Coding Initiative (CCI) edits. The carriers manual section 4630(D.4.c) instructs providers to attach modifier -59 to the lesser procedure(s).
 
An example of a bundled coding combination requiring modifier -59 is a colonoscopy by snare technique (45385) in one part of the colon and a control-of-bleeding technique (45382) performed on an arteriovenous malformation (AVM) in another part of the colon. The special payment rule for multiple endoscopies applies because these procedures have the same base code, 45378. In addition, 45382 is a component of 45385, CCI states.
 
"If the procedures are bundled in the CCI, but performed in different areas and are separately reportable, then modifier -59 should be attached," says Mary Lou Masters, billing representative with the University of North Texas Health Science Center, a multispecialty practice with three gastroenterologists in Fort Worth, Texas.

Modifier -51 still has a loyal following of coders who code it primarily because it has been prescribed in Medicare's national policy, and they have no problems getting their claims reimbursed. Masters has successfully billed the modifier for years, in Texas and Pennsylvania, where she worked previously. "This is the national standard," she says. "Just because a carrier or payer doesn't understand it doesn't mean we shouldn't use it."
 
In the above example of multiple ERCP procedures, Masters would report the procedures on a claim in the following manner and order: 43265, 43264-51 and 43262-51.
 
With the advent of more highly computerized claims systems, many coding experts no longer feel the need to report modifier -51 and have simply stopped billing it. "I tend to leave it off," says Terry A. Fletcher, CPC, CCS-P, CCS, a healthcare coding consultant in Laguna Niguel, Calif. "If the insurance carriers want to modify a procedure, then they can."
 
Fletcher continues to code modifier -59 in the manner prescribed by Medicare's national policy, for those procedure combinations that are bundled in the CCI edits.
 
She would report the multiple ERCP procedures in the same order that Masters did, without any modifiers: 43265, 43264 and 43262.

Others who discontinued billing modifier -51, often code modifier -59. "Anytime I have more than one procedure in the same endoscopic group of families, like two colonoscopy procedures or two esophagogastroduodenoscopy (EGD) procedures, I use modifier -59," says Linda Parks, MA, CPC, lead coder at Atlanta Gastroenterology Associates, a 23-physician practice. "If two codes are bundled in the CCI edits, I use modifier -59, but there aren't that many that are bundled for gastroenterology."
 
Reporting a different modifier has had a big impact on the reimbursement of claims filed by Parks with commercial insurers. "When I first started coding, I used modifier -51, but so many of our commercial payers were ignoring it and bundling the procedures," she explains. "Around 18 months ago, I stopped using it because someone at a coding workshop suggested that I use modifier -59 instead, and that's when I changed. Some payers will still bundle the procedures no matter what you put on it, but we have been getting fewer denials and fewer instances of bundling with modifier -59."
 
Parks would code the procedures in the ERCP example, in the same order with modifier -59: 43265, 43264-59 and 43262-59.
 
Parks uses modifier -51 only to report the relatively new Stretta procedure, which treats gastroesophageal reflux disease. In that situation, 64640 (destruction by neurolytic agent; other peripheral nerve or branch) is coded twice to report the destruction of nerves in both the lower esophageal sphincter and the cardia. Parks adds modifier -51 to 64640 when she lists it for the second time, upon the recommendation of the manufacturer of the equipment used during the procedure.
 
Note: For a more detailed explanation of coding for the Stretta procedure, see "Get Reimbursed for the Stretta Procedure with Four Crucial Steps" on page 25 of the April 2001 Gastroenterology Coding Alert.

In a sort of belt-and-suspenders approach to coding, some have advocated reporting modifier -51 and modifier -59 in certain situations. The American College of Gastroenterologists previously stated that when a physician biopsies a polyp (45380) and then performs a polypectomy by snare technique (45385) or another method, "both the biopsy and snare removal are billable. The second or lesser procedure should include modifier -51 for multiple procedures and also modifier -59, showing this was a separate, distinct procedure."
 
Despite their different coding methods, none of the coding experts interviewed for this article could recall a situation that required the use of both modifiers. Even Masters, the modifier -51 hold-out, says that "it probably could be done, but I can't say in what instance that would be."

Oddly enough, all three coders would use modifier -59 to report multiple surgeries for unrelated procedures, even though Medicare says that no modifier is needed in this situation. In the previous example of a diagnostic EGD (43235) and a colonoscopy by snare technique (45385) performed on the same day, all three coders would report 45385 first because it is the higher-valued procedure, and then 43235-59.
 
"These are two totally unrelated procedures, so you can't use modifier -51 because it is for multiple procedures in the same family," Masters explains. "Modifier -59 indicates that these are separate and distinct procedural services."
 
There's also a feeling that sometimes a payer will deny a claim no matter which modifier is coded. "I was always taught to use a modifier and that reimbursement was increased because of modifiers, but even if you add the appropriate modifier, you may end up appealing," Masters says. "We've learned to send the operative notes along with the claims."