Gastroenterology Coding Alert

Your CPT should jive on both physician's notes, or else you can bid your claim goodbye.

When you come face-to-face with a multi-provider situation, the last thing you would want is to mess up your coding by assigning the wrong modifier(s). Modifiers can be a friend or a foe, depending on how you use them -- or when you use them.

Scenario: Gastroenterologist X is the primary caregiver for a patient with severe weight loss. He goes to the hospital to meet the patient, who is weak from starvation. With the help of Gastro Y, Gastro X inserts a PEG tube.

The main key in a multi-provider scenario is to treat each physician's work as a separate activity. However, deciding when to report a case as co-surgery, assistant surgery -- or something else --" has more to it than meets the eye. Find out what with this expert's advice.

Modifier 62, 81, 82 and the Roles They Play

You know that a modifier is at hand in this case, but more importantly you should be able to tell what role each modifier plays in order for your procedure codes to blend well together.

Here are the most common modifiers used in multi-provider

• Modifier 62 (Two surgeons). Append this to each surgeon's procedure when the physicians perform distinct, separate portions of the same procedure. Also referred to as co-surgery, modifier 62 tells you that each physician completed a single procedure within the overall surgery. Look for a hint in the operative notes, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC, senior coder and auditor for The Coding Network, and president of CRN Healthcare Solutions. Both surgeons should dictate their own op notes to describe their roles in that single procedure, she says. Modifier 62 is your best bet for insertion of a PEG tube when one gastroenterologist performs the endoscopic portion and another gastroenterologist (or surgeon) performs the percutaneous puncture portion on the abdomen.
• Modifier 80 (Assistant surgeon), modifier 81 (Minimum assistant surgeon), and modifier 82 (Assistant surgeon [when qualified resident surgeon not available]) are used in standard surgeries when one surgeon assists the other with multiple portions of the case rather than completing his work independently. (Not used in gastroenterology procedures)
• Attach modifier AS (Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery) when you report a nonphysician practitioner's (NPP's) involvement to Medicare. (Not used in gastroenterology procedures)

Warning: Not all payers recognize modifier AS. It's better that you verify the correct way to report the NPP's service before completing your claim.

Avoid the Modifier 51 Trap

It's easy to fall into the lure of using modifier 51 (Multiple procedures) when you're coding for multiple procedures during the same operative session, but you could end up in the gutters if you're not careful enough.

Why: Modifier 51 tells you that a surgeon was present performing multiple procedures. If a surgeon is not physically present for multiple procedures in a surgical case, it's not appropriate to indicate that he was by using modifier 51.

Two Surgeons Require Two Mirror Claims

In the scenario given, you should report 43246 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube) for the PEG placement. Then, you would use 994.2 (Effects of hunger) with 43246 to describe the diagnosis. Finally, you should append modifier 62 to 43246 to show that two gastroenterologists performed the insertion. Both providers should complete a report of the services they performed, both would use 43246-62 to file their claims, and they should each be paid half of 125 percent of the usual reimbursement of 43246.

Catch: You don't use modifier 62 if the physicians are not reporting the same CPT code. If each doctor can represent his work with a separate CPT code, skip modifier 62. Make sure both physicians send a claim with the same code and modifier declared.