Gastroenterology Coding Alert

Billing for more than one endoscopic procedure performed during the same session can be confusing for many gastroenterologists. What codes and modifiers to use for reporting multiple endoscopic procedures will depend on which parts of the body the procedures are performed, whether the procedures are bundled together in the Correct Coding Initiative (CCI), and on local payer policies.

Performing an upper gastrointestinal procedure, like an esophagogastroduodenoscopy (EGD), and a colonoscopy on a patient on the same day is not unusual and may be done for a variety of reasons, according to Delbert Chumley, MD, Carrier Advisory Committee (CAC) representative for gastroenterology in Texas, treasurer of the Texas Society of Gastroenterology and Endoscopy, and a member of the board of trustees for the American College of Gastroenterology.

Multiple procedures are often done on the same patient, usually for purposes of evaluating a condition such as anemia, gastrointestinal bleeding or chronic diarrhea. Or it could be that the patient has two different conditions, such as a swallowing problem and a polyp in the colon, he explains. Doing two procedures on the same day is not only more economical, but also easier for the patientparticularly as it pertains to time off from work, transportation, etc.

State-Specific Requirements

A gastroenterologist in Pennsylvania who is billing a colonoscopy (45378) and an EGD, for example, would list both procedures without any modifier. In the Correct Coding Initiative (CCI), there are no audits or edits that would indicate these are bundled procedures, says Andrew Bloschichak, MD, carrier medical director for Xact Medicare Services, Pennsylvanias Medicare carrier in Camp Hill. There should be no problem with just listing the two procedures on the claim without any modifiers. The fee on the lesser-valued procedure, which should be listed second, would be reduced, however.

This is not the way that all payersboth commercial and Medicarewould handle the situation. In Texas, Chumley advises using modifier -51 (multiple procedures). For multiple procedures done on the same day, where the procedures are from different families of CPT codes, attach modifier -51 to the lesser-valued procedure, recommends Chumley, who adds that the fee for the lower-valued procedure usually is reduced by 50 percent.

Use Modifier -59 for Bundled Procedures

Many gastroenterologists may be tempted to use modifier -59 (distinct procedural service) instead, but Chumley feels that this situation clearly calls for modifier -51. Modifier -59 should be used when procedures are being performed on different pathological sites within the same family of CPT codes and there is a question of bundling [by CCI], he notes.

Two codes that are bundled by the CCI are polypectomy via snare technique (45385) and control of bleeding (45382), which both refer to procedures performed in the colon. Medicares first assumption when it sees both of these codes on the same claim, according to Chumley, is that the gastroenterologist first removed a polyp that bled and then cauterized the site of the polypectomy to control the bleeding. In that situation, Medicare will reimburse only for 45385.

If a polyp is removed in the sigmoid colon, however, and then a control of bleeding procedure is performed on an arteriovenous malformation (AVM) in another area such as the ascending colon, then attaching modifier -59 to the lesser-valued procedure, which in this case is code 45385, is appropriate, says Chumley. Medicare will reimburse the lesser-valued procedure at a reduced rate because two distinct services were performed in two different pathological sites of the colon.

Note: Some payers may require gastroenterologists to attach the modifier -59 to the procedure that otherwise would be denied, which in the above example would be 45382 and not the lesser-valued procedure.

Requirements Vary From Payer to Payer

Various payers may handle the same coding situation differently, which means that gastroenterologists need to contact their local payers to get specific coding instructions. Some payers do not require physicians to attach modifier -51 on Medicare claims because the Part B carriers claim system is designed to pay this coding combination under the rules for multiple, unrelated endoscopic payments.

On the other hand, some payers may require modifier
-51 or even modifier -59. For example, a third-party payer may require physicians to use modifier -59, even when modifier -51 seems more appropriate. Therefore, you should familiarize yourself with local third-party payer reporting and reimbursement policies because they may vary from CPT coding guidelines.

Covered Diagnosis Codes Must Be Used

Another key to receiving reimbursement for multiple procedures is using appropriate ICD-9 codes in the claim.
If the CPT codes are correct, then youd have to take a look at what diagnosis codes are being used to support the medical necessity, says Bloschichak.

A diagnosis code covered by the Medicare payers local medical review policy must be used in the claim, according to Chumley. In addition, he tries to use a different diagnosis code for every procedure he performswhen possible. If the patient is being evaluated for anemia, and the gastroenterologist finds stomach cancer, then diagnosis code 280.0 (anemia due to blood loss) could be used for the colonoscopy and code 151.2 (malignant neoplasm of the stomach; pyloric antrum) could be used for the EGD, Chumley explains. Initially, you can use a diagnosis code that is covered for both procedures, he advises. If you find something during the procedure, then go and change the diagnosis code to reflect what you found.

Finally, if a gastroenterologist uses a modifier, the documentation in the patients operative report should explain why, claims Chumley, who suggests that physicians clearly state in their notes the different areas of the body that they are dealing with and why. Highly detailed notes make it easy for an appeal because your staff can look at your dictation and identify the reason for a modifier, Chumley says. If your dictation is sloppy, you may not be able to recall the details of the procedure to include in your appeal letter.