Gastroenterology Coding Alert

If you confuse comprehensive codes with diagnostic (base) codes, you could be leaving crucial codes off your claim or using the wrong modifier, which could result in loss of payment.

Make sure your claims are compliant by testing yourself with this example submitted by a Gastroenterology Coding Alert subscriber:

Scenario: "The doctor performed an EGD/dilation and biopsy of an esophageal stricture. Would you bill both the 43248 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with insertion of guide wire followed by dilation of esophagus over guide wire) and the 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple) with the appropriate modifier?

Or, do you think the "same site" rule would apply, and therefore you should only bill the procedure with the higher relative value units (RVUs)?"

You'll need to know one over-arching CPT guideline to determine the code combination you're allowed to report with multiple scope procedures.The "same site" or multiple endoscopy rule is that comprehensive codes are included or "bundled" in with the diagnostic code. "Only the most extensive procedure would be billed," says Kathleen A. Mueller, RN, CPC, CCS-P, CMSCS, PCS with Askmueller Consulting in Lenzburg, Ill.

The diagnostic base code is 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 procedures]). The 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple) and 43248 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with insertion guide wire followed by dilation of esophagus over guide wire) codes are both comprehensive codes in that same family of codes. Therefore, you cannot report 43239 or 43248 and 43235 for the same operative session.

Medicare follows CPT rules in its payment policies. If there are no Correct Coding Initiatives (CCI) edits  bundling scope codes together, then you can report the component or less extensive code with the comprehensive or more extensive code. You would be paid 100 percent on one and then the difference between the second code and the base procedure on the additional code.

You don't need to add modifier 51 (Multiple procedures) since the Medicare software can automatically  detect that there are two codes that will be paid, with a reduction on the lesser valued comprehensive code.

"Modifier 51 is appropriate from a correct coding perspective, but is not required for payment on claims," says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine.

You do need modifier 59 (Distinct procedural service) if there is a CCI edit indicating that one code is a component of another comprehensive code.

Knowing what the payers you work with require is the key to success in billing multiple endoscopic procedures. Private payers may need modifier 59 on one of the codes to override their own individual software program. They may pay 100 percent on both codes or some lesser amount for the lesser-valued procedure.

You may need modifier 51 if your payer isn't able to detect multiple procedures. Medicaid is the most likely to require modifier 51.

Note: You do not need to list procedures in any particular order on the claim form but if you use modifier 51 it is important that you apply it to the right codes. There may be a few minor payers who will pay the lower code at full price and the higher code at half price if the codes are listed out of order. There may be a few minor payers who do this but overall this is an old and outdated concept.