Gastroenterology Coding Alert

When a gastroenterologist is asked as a consultant to see a patient in the hospital, and performs a procedure on that patient on the same day, the procedure and the consult (99251-99255) should be reimbursed. But this doesnt always work. The answer, our sources say, is to use the modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on the consult.

Take the situation of John Zak, III, MD, a gastroenterologist practicing in Daytona, FL. If he sees a patient in the hospital and places a gastrostomy tube, he wont get paid for the consult as well, says his office administrator Justine Barker. This procedure involves an endoscopy prior to the tube placement, Barker explains; the code is 43246 (upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube). In a recent case, Zak was called in to see a patient who had been admitted for weight loss and aspiration. She was choking and starving, Barker says. So Zak had to put in a tube. Shortly thereafter, the patient was discharged. Medicare denied payment for the consult, saying that multiple procedures on the same day are not covered, says Barker. They also said the tube placement could have been done on an outpatient basis.

The solution to Barkers coding problem is modifier -25, says Margaret Stewart, billing supervisor for Gastroenterology Group, a nine-gastroenterologist practice in Washington, D.C. Put a modifier -25 on the consult, and you will increase your chances of getting paid, says Stewart, noting that this strategy works for her. We may have to send the claim again, she relates, but we do get paid. The work done by Zak, therefore, should be coded as 9925x-25, and 43246. (Note that the x signifies that you insert the digit that correctly conveys the work done by your physician.)

Technically, you should not have to use modifier -25, says Glenn D. Littenberg, MD, who is a member of the American College of Physicians-American Society of Internal Medicines Committee on Payment and Coding. If you are called in to see someone elses patient, and you do a procedure on the same day, you should get paid for the consult as well as the procedureespecially by Medicare, he says. Any carrier who is not following these rules should be chastised.

Also, it is no longer necessary to have a different diagnosis for the two procedures done. In CPT 1999, the definition of modifier -25 was altered to include the verbiage: The E/M service may be prompted by the symptom or condition for which the procedure [...]