Gastroenterology Coding Alert

Modifier 59 may not be part of every multi-EGD claimTo determine if your gastroenterologist merits more than one upper gastrointestinal endoscopy (EGD) CPT code for 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.Best advice: "Software isn't foolproof, so I always read the entire op note and code from there," says Christine W. Harvey, LPN, CPC, charges and coding specialist at the Indianapolis Endoscopy Center in Indiana.Gather Your Payer InformationWhen reporting multiple endoscopies from the 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate...) "family," make sure you get the code order right. Then, you must know each of your payers' reporting guidelines."Payers may not allow you to bill certain services together," says Dena Remisek, biller for Grand River Gastroenterology, P.C. in Grand Rapids, Mich. "Check for billing edits and add appropriate modifiers."Bottom line: Although an upper gastrointestinal endoscopy takes a lot of time and expertise, multiple endoscopies 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 CodeWhen physicians perform multiple GI endoscopies, you're most likely to see 43239 (... with biopsy, single or multiple) in combination with other codes from the 43245 family. In such a case, you should be sure to claim all reportable procedures to capture fully all the reimbursement your physician deserves."When an MD performs multiple EGD procedures in the same code set family [such as 43245 and 43239], you may submit both codes for payment," says Susan Lariviere, CPC, MA, coder and auditor for RiverBend Medical Group in Agawam, Mass.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.Note: Although 43255 has a higher relative value unit (RVU) than 43239, when your gastroenterologist performs 43255 and 43239 together, you should put modifier 59 on 43255. This indicates that "the biopsy wasn't the cause of the bleed," Rumisek says.Other multiple EGD scenarios you may see often include EGD with biopsy 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 or bipolar cautery; 43251, ... with removal of tumor[s], polyp[s], or other lesion[s] by snare technique)
 • band [...]