Gastroenterology Coding Alert

Gastroenterologists may be familiar with how to code for two endoscopic procedures done on the same day by applying either the multiple surgeries or multiple endoscopic procedure payment rules and attaching the appropriate modifiers. When a gastroenterologist performs three or more endoscopic procedures on the same day, however, both payment rules may have to be used when preparing the claim.

Medicare uses two payment rules when reimbursing for multiple endoscopic procedures. To receive payment under either one of these rules, the claim and its documentation should reflect the medical necessity for doing each procedure, which is indicated by using the most appropriate ICD-9 code, says Pat Stout, CMC, CPC, an independent gastroenterology coding consultant in Knoxville, Tenn. These rules are:

1. Standard Payment Rule for Multiple Surgeries. If two or more procedures with different endoscopic base codes are reported on the same day, the procedures should be listed on the claim in descending order according to their relative value units (RVUs). The procedure that has the highest RVU will be reimbursed at full value. Medicare will reimburse the other procedures at 50 percent of the value of their usual fee.

Because these procedures have different endoscopic base codes, they are referred to as being from unrelated endoscopic families.

The Medicare Carriers Manual states that the lesser-valued surgical procedures should be reported with modifier -51 (multiple procedures). But this is not required by all local Medicare payers or commercial insurance companies. (For more on this, see Increase Reimbursement with Correct Modifiers and ICD-9 Codes on page 19 of the March 2000 Gastroenterology Coding Alert.)

2. Special Payment Rule for Multiple Endoscopies. If two or more endoscopic procedures with the same endoscopic base code are reported on the same day, the procedures should be listed on the claim in descending order according to their RVUs. Reimbursement will include the full value of the procedure with the highest RVU, plus the difference between the value of the other procedures and their endoscopic base codes.

Because these procedures have the same endoscopic base code, they are referred to as being from related endoscopic families. Multiple procedures from related endoscopic families require the use of modifier -59 (distinct procedural service) if the procedures are bundled together in the Correct Coding Initiative (CCI). The Medicare Carriers Manual states that modifier -51 should be used if the procedures are not bundled. But this may not be a requirement of all local payers.

Related and Unrelated Procedures on the Same Day

When related and unrelated endoscopic procedures are performed on the same day, both sets of payment rules must be applied. The Medicare Carriers Manual states that when two sets of unrelated endoscopies are performed, the special endoscopy rules are applied to each set before applying the multiple surgeries rules.

If an esophagoscopy with biopsy (43202) and esophagoscopy with snare (43217) and an anoscopy with biopsy (46606) and anoscopy with removal of foreign body (46608) are performed on the same day, for example, the two esophagoscopy procedures are considered to be one set, and the two rectal procedures are a second.

For billing purposes the services would be listed in descending order according to their RVUs, according to Stout, who explains that the coding and reimbursement for each procedure would be as follows:

1. Code 43217. Of the four procedures, this one has the highest RVU. No modifier is needed. No special payment rules apply. This service would be reimbursed at its full value.

2. Code 43202-59. The endoscopic base code (43200) for this procedure is the same as code 43217, therefore, the special endoscopy rule applies. Reimbursement is the difference between the full value of the procedure and its base endoscopic code. Assume the value of code 43202 is $135 and the value of code 43200 is $117. Therefore, reimbursement would be $18. Modifier -59 is attached because code 43202 is bundled into code 43217.

3. Code 46608-51. This procedure is the higher-valued anoscopic service, and its unrelated to the esophagoscopy procedures, so only the multiple surgery rule applies. If this service is valued at $95, reimbursement would be 50 percent of the full value or $47.50. Modifier -51 is attached because this is a lesser-valued multiple surgery and is not bundled with any of the other procedures.

4. Code 46606-51. The endoscopic base code for this procedure (46600) is the same as code 46608. The special endoscopy rule is applied, followed by the multiple surgeries rule. If the value of 46606 is $43 and the value of 46600 is $27, the difference is $16. Reimbursement would be 50 percent of this amount or $8. Modifier -51 is attached because this is a lesser-valued multiple surgery and is not bundled with any of the other procedures.

Procedure Repeated Later in the Day

Another situation involving three or more procedures might occur when a patient has to have an endoscopic procedure repeated on the same day. A patient has hematochezia, or the passage of blood in the feces. An upper gastrointestinal endoscopy (43235) is performed, but the source of the hematochezia is not discovered. A colonoscopy is then performed, and a polyp is removed via the snare technique (45385). The patient is discharged but returns later in the day because of rectal bleeding. A second colonoscopy is performed to recauterize the polypectomy site and stop the bleeding (45382).

Stout believes the coding and reimbursement in this situation would be as follows:

1. Code 45382-59 and -76. Because 45382 is bundled into 45385 in the CCI, Stout says that the modifier -59 should be attached to this service because its the procedure that would otherwise be denied. Modifier -76 (repeat procedure by same physician) may be used, according to Stout, to indicate that this second colonoscopy was performed during a different session.

Although the Medicare payment policy would indicate that this procedure should be reimbursed at its full value because it is the service with the highest RVUs, Stout believes local payers may have their own payment policies for this type of situation and suggests that gastroenterologists contact their local payers to get specific billing and payment information.

2. Code 45385. The endoscopic base code for this procedure (45378) is the same as code 45382, so the special endoscopy rule applies. Reimbursement is the difference between the value of this procedure and the endoscopic base code. If the value of 45385 is $375 and 45378 is $262, reimbursement is $113. No modifier is needed.

3. Code 43235-51. This endoscopic procedure is unrelated to the other procedures, and only the multiple surgery rule applies. If the value of the procedure is $168, reimbursement is 50 percent of the value or $84. Modifier -51 is attached because this is a lesser-valued multiple surgery and is not bundled with any of the other procedures.

Three or More Related Endoscopic Procedures

Occasionally, three or more multiple procedures per-formed on the same day do not require the use of both pay-ment rules. For example, when a polypectomy via the snare technique (45385) is performed in one area of the colon, a polypectomy via hot biopsy forceps (45384) is done in another area, and control of bleeding is done in still another section of the colon (45382), only the special endoscopic procedure payment rule would be applied, explains Stout.

Coding and reimbursement for this situation would be as follows:

1. Code 45382-59. This is the highest valued procedure of the three. No special payment rules apply. Reimbursement is for the full value of the procedure. Because CCI bundles 45382 into 45385 and 45384, Stout says that modifier -59 must be attached to this code because its the procedure that would be denied otherwise.

2. Code 45385. The endoscopic base code (45378) for this procedure is the same as for 45382, so the special endoscopy rule applies. Reimbursement is the difference between the value of this procedure and its endoscopic base code. If the value of 45385 is $375 and 45378 is $262, reimbursement would be $113. No modifiers are needed.

3. Code 45384-51. The endoscopic base code (45378) for this procedure is the same as codes 45385 and 45382, so the special endoscopy rule applies. Reimbursement is the difference between the value of the procedure and its endoscopic base code. If the value of 45384 is $332 and 45378 is $262, reimbursement would be $70. Modifier -51 is attached because this procedure is related to, but not bundled with, code 45385.

More Than Perfect Coding Required

Even if a claim is coded perfectly in compliance with Medicares guidelines, it frequently will be rejected, according to Albert Shaw, practice manager at Asher, Kornbluth MDPC, a three-physician gastrointestinal practice in New York City. Its been my experience that if you are reporting unrelated procedures to Medicare such as an upper gastrointestinal endoscopy and a colonoscopy, you will get paid most of time, he says. But if you are reporting related endoscopic procedures, its likely that you will be rejected.

In addition to coding the claim correctly, Shaw offers the following suggestions when reporting
multiple procedures:

The operative report should explain why multiple procedures were necessary. If two methods were used to remove polyps, then the gastroenterologist needs to explain why he or she switched methods, notes Shaw. Even though in theory you should get reimbursed if you used two removal methods, Medicare will wonder why you didnt remove them all with one method, he says. They may think youre just trying to get extra reimbursement unless theres some explanation.

The gastroenterologists in Shaws practice also label a diagram of the digestive system that is included in the operative report and indicates what was done where on the patient. If a polyp is removed from the rectum, then that point could be given a label, such as 1-a, in the diagram. A corresponding note labeled 1-a is also made in the operative report where the gastroenterologist explains what was removed, how it was removed and why.

Create form letters to send to those payers that repeatedly are rejecting your multiple procedure claims. Shaw has identified which payers are rejecting what combinations of procedures and has created more than 25 different form letters to send along with the claims that contain those combinations. In the letters, he cites the section of the policy that he believes supports his claim.

Use Medicare guidelines with commercial payers. Although Medicare created the multiple procedure rules, many commercial insurance companies also have adopted these rules, says Shaw. When he is fighting for a claim with a commercial payer, he has found it useful to cite Medicare guidelines and to state this is the national policy. He also has found that an easy way to have official sounding appeals is to save correspondence from Medicare and use the information cited by the agency in his letters to insurance companies.

Be prepared to fight, he advises. You should be paid, especially in the case of upper and lower gastrointestinal endoscopies. But even with the losers, such as those claims with poorly documented operative reports, I fight for those as well. Who knows? Maybe youll get paid.