Reviewed on May 13, 2015
Modifier -59 may not be part of every multi-EGD claim
When your gastroenterologist performs more than one upper gastrointestinal endoscopy (EGD) on the same patient during the same encounter, you should look for biopsy details and such procedures as polyp removal and band ligation in the op notes.
Pay Attention to Payer Guidelines, Code Order
When reporting multiple endoscopies from the 43235 family (Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]), make sure you get the code order right.
Then, you must know each of your payers’ reporting guidelines, says Sherri Brasher, insurance and billing specialist at Gastroenterology Associates in Evansville, Ind.
Why? While an upper gastrointestinal endoscopy takes a lot of time and expertise, multiple endoscopies only require more of each. If you can’t report these encounters correctly, the claim may not secure your practice rightful payment for the encounter.
Know 43239: The Most Frequent Multi-EGD Code
“There are many EGD combos that our physicians perform within the 43235 family,” Brasher says. However, most of those code combos include CPT® code 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple)
For example, if the gastroenterologist treats a patient for bleeding gastric ulcers, he may also take a biopsy in a separate upper GI area. When this occurs, you should:
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report the biopsy with 43239.
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use 43255 (... with control of bleeding, any method) to report the ulcer treatment.
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attach modifier -59 (Distinct procedural service) to 43255 to show that the biopsy and ulcer care occurred at different sites. With the addition of new X{EPSU} modifiers, some payers may require you to report modifier XS (Separate structure) to report the scenario.
Note: Although 43255 has higher relative value units (RVUs) than 43239, when your gastroenterologist performs 43255 and 43239 together, “you have to place the modifier -59 on 43255 to indicate that the [bleeding] was separate from the biopsy and not caused by the biopsy,” Brasher says.
Other multiple EGD scenarios Brasher sees often include EGD with biopsy in conjunction with:
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saline or Botox injection (43236, ... with directed submucosal injection[s], any substance)
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removal of tumor/polyp (43250, ... with removal of tumors[s], polyp[s], or other lesion[s] by hot biopsy forceps;43251, ... with removal of tumor[s], polyp[s], or other lesion[s] by snare technique)
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band ligation of varices (43244, (… with band ligation of esophageal/gastric varices).
Code Combos Can Vary By Office
Margaret Lamb, RHIT, CPC, has coded for many types of multiple EGDs in her career. However, “the most common [multiple EGD] scenario I come across is an esophageal dilation done in conjunction with a biopsy at a different site,” says Lamb, of Great Falls Clinic in Great Falls, Mont.
Scenario: A patient with dysphagia and reflux symptoms reports to the office. The gastroenterologist dilates the esophagus with a balloon catheter and biopsies a separate area where he suspects Barrett’s esophagus. On the claim, Lamb says you should:
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report 43249 (...with transendoscopic balloon dilation of esophagus [less than 30 mm diameter]) for the dilation.
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attach ICD-9 codes 787.2 (Dysphagia) and 530.81 (Esophageal reflux) to 43249 to prove medical necessity for the dilation. For accurately reporting dysphagia under ICD-10, you will have to check category R13.- (Aphagia and dysphagia) and the ICD-10 crosswalk for reflux will be K21.9 (Gastro-esophageal reflux disease without esophagitis).
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report 43239 for the biopsy.
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attach ICD-9 code 530.85 (Barrett’s esophagus) to 43239 to prove medical necessity for the biopsy. The ICD-10 crosswalk for Barett’s esophagus is K22.70.
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attach modifier -59 to 43239 to show that the biopsy was separate from the dilation. Although modifier 59 may still be acceptable, depending on the documentation, you may have to report either modifier XS (Separate structure) or XU (Unusual non-overlapping service) instead under the new 2015 X{EPSU} modifiers.
Check Payers’ Modifier Requirements, Then File
Whether or not you should use modifiers on your multiple EGD claim will depend on the situation. You may be tempted to slap modifier -59 or any of the new X{EPSU} modifiers on each multiple EGD claim without even thinking about it. However, if you’re not sure that every payer wants modifier -59 on a multiple EGD claim, you cannot be sure that the claim will be clean.
In Lamb’s office, “if the [EGD] code is in the same family, [one of the codes] will be subject to bundling unless you attach modifier -59” with her insurers, she says. However, it may not be so simple in your neck of the woods.
Consider this example: The gastroenterologist performs an upper GI EGD with biopsy and a guidewire esophageal dilation in the same session. The CPT® codes for this example are always the same.
On the claim, regardless of payer, you should:
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report 43248 (… with insertion of guide wire followed by passage of dilator[s] through esophagus over guide wire) for the dilation.
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report 43239 for the biopsy.
However, the modifiers you attach on this claim will depend on your payer. Many coders would likely have to attach modifier -59 to 43239, but “in Indiana, in order to get this combination paid, we have to attach modifier -59 and modifier -51 (Multiple procedures) for [many] commercial payers.” Brasher says.
Why? “We use both modifiers because we found that in appeals, if we explain the use of each modifier, the payer understands the claim better and the appeal stands a better chance of acceptance,” Brasher says.
As for leaving modifier -59 off the Medicare claim, Brasher says she “only attaches modifier -59 if the procedures are bundled” and she needs “to indicate that there were two separate procedures performed at two separate locations.”
Best advice: Don’t generalize. Take the time to learn each payer’s specific rules on reporting multiple EGDs. Some payers will want you to use a combo of modifiers; others might not want to see any modifiers at all. It’s up to the coder to know all payer guidelines before a multiple EGD claim hits her desk.”
