Gastroenterology Coding Alert

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: report the biopsy with 43239. use 43255 (... with control of bleeding, any method) to report the ulcer treatment. 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: saline or Botox injection (43236, ... with directed submucosal injection[s], any substance) 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) 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, [...]