Gastroenterology Coding Alert

Veterans recommend grouping modifiers by function for training

If you're looking for a quick run-down of basic modifier concepts to keep handy for training purposes in your gastroenterology office, use these time-tested pointers provided by a veteran coding trainer.

The right modifier is often the difference between an approved and a rejected claim, says Carol Buck, CPC, author of a series of coding instruction manuals, including Step-by-Step Medical Coding.

To neglect modifier training for new coding employees is unwise; even though it may save time now, you could be paying for it in the future.

When you teach modifiers, group them by function, says Laureen Jandroep, OTR, CPC, CCS-P, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J., and AAPC National Advisory Board Member.

"For example, teach all of the global-package modifiers as a group, then all of the modifiers related to the number of surgeons in the operating room (co-surgery, assistant at surgery, etc.)," Jandroep says.

Also, remind new coders that if the patient is not in a global period, then none of the global-package modifiers apply, "so know when your global periods end to avoid unnecessary modifier use," Jandroep says.

Jandroep suggests that you stress the following modifier fundamentals.

Modifier -59 (Distinct procedural service) is the modifier "of last resort." The CPT definition for -59 (in Appendix A of CPT 2004) directs coders not to use -59 "when another already established modifier is appropriate."

This is a common code modifier for gastroenterology offices because of all of the National Correct Coding Initiative (NCCI) edits that bundle different techniques unless you use modifier -59.

You should use modifier -62 (Two surgeons) only when the co-surgeons share the same CPT code. If they can individually represent their work with their own CPT codes, then they don't need to use modifier -62.

Example: In a gastroenterology office, coders would most likely use modifier -62 on the endoscopy with a PEG-tube placement procedure (CPT code 43246, Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube).

You can append modifier -21 (Prolonged evaluation and management services) only to the highest-level codes per category/subcategory.

For example, if the gastroenterologist provides prolonged E/M services for a new patient, you would append modifier -21 only to new patient code 99205 (Office or other outpatient visit for the evaluation and management of a new patient, hensive history; a comprehensive examination; and medical decision-making of high complexity). You cannot append modifier -21 to 99201 through 99204 because they are not the highest level.

When using modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), make sure there is clear documentation of a history, exam, and medical decision-making (MDM) in addition to a separate note for the procedure being done at the same time.

Example: A primary-care provider asks a gastroen-terologist to consult on a patient with abdominal pain and bloody diarrhea. The patient undergoes a flexible sigmoidoscopy and biopsy after a level-three consultation.

You should: