Gastroenterology Coding Alert

Hint: Modifier 80 is not always your best bet.

When your gastroenterologist works with another physician during a procedure, you could be in for major coding challenges. You will need to coordinate your coding with the other physician’s coder. If you don’t, both doctors could lose money and face audit scrutiny.

Learn about how to correctly code for procedures shared by two physicians with this real-world case study.

Review the Surgical Case

Scenario:  A gastroenterologist and a general surgeon performed surgery on a patient. Both physicians worked together on the same procedure. The gastroenterologist performed an endoscopy to locate the correct position along the stomach wall for placement of a percutaneous endoscopic gastrostomy (PEG) tube. The general surgeon made an incision at the same position into the wall of the stomach and used a retention disk to put the PEG tube in place and secure it. Both physicians are going to report the same procedure code.

1 Procedure = 1 CPT^® Code + Modifier 62

In this case, each physician would bill using the same code: 43246 (Esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube). Both coders would also append modifier 62 (Two surgeons).

Pointer: You should only report co-surgeons (using modifier 62) if two doctors are doing the same procedure, using the same procedure code, but each doing a component different from the other. Each surgeon must perform a distinct part of one procedure and must account for that operative work by appending modifier 62 to the code that best represents the service provided.

Beware:  The rules about when you can and can’t use modifier 62 may vary by MAC or payer, so be sure to check your regulations and your individual payers to see if modifier 62 is right for your practice. CMS’ reimbursement policy is to pay 125 percent of the usual fee, split evenly (62.5 percent of usual fee) between the two physicians, said Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel member in Pasadena, California. “Many contractors, however, will not reimburse two physicians of the same specialty,” he said.

Skip Modifier 80

You might be tempted to append modifier 80 (Assistant surgeon) but that modifier is not appropriate since the surgeons in this case are not assisting each other. When each physician takes the lead in some aspect of the procedure, you’ll use modifier 62. Use modifier 80 instead when one physician directs the entire procedure and the other just assists at the primary physician’s direction.

Pointer: Correlating your coding with the second surgeon’s coder is beneficial, especially if the doctors are not part of the same practice. This will ensure both parties are coding the same and reduce the chance of a denial.

If the PEG tube placement described above was performed by two gastroenterologists-- one who led the procedure and the other who acted as a second set of hands to get the PEG tube in the right location-- the primary physician would report 43246 without a modifier and the assistant would report 43246-80 to indicate that he was an assistant.

Warning: Some Medicare carriers and private payers may specify that you have to code dual-physician PEG tube placement by indicating one physician as the assistant, especially when two gastroenterologists perform the PEG tube placement.