Gastroenterology Coding Alert

Medicare often includes control of bleeding in its reimbursement for endoscopic polypectomies, assuming that the bleeding has been caused by the removal of the polyp, tumor or lesion. But under certain circumstances, gastroenterologists can bill separately for the procedure.

The amount of bleeding involved in most polypectomies usually is not significant and often is controlled by the electrical current used to excise the polyp, according to Kathy Anderson, RN, director of nursing and plant manager of the Indianapolis Endoscopy Center, an ambulatory surgical center serving four gastroenterologists.

On the other hand, there are many situations when the gastroenterologist will perform an endoscopy where the primary purpose ends up being to control bleeding. A heater probe, bi-cap probe or a laser is used to cauterize the bleeding tissue. Some gastroenterologists may prefer to use an injection of epinephrine to control any hemorrhaging.

These control of bleeding techniques frequently are used on arteriovenous malformations (AVMs) and cases of diverticulosis. A patient also may have bleeding tumors or polyps that are too large to be removed endoscopically and must be cauterized to temporarily stop the bleeding until they can be removed surgically. Another situation requiring cauterization is post-polypectomy bleeding, which can occur as much as two weeks after the original procedure, requiring the gastroenterologist to re-insert the endoscope.

In these cases, gastroenterologists should bill for an endoscopic control of bleeding and use a code such as 43255 (upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with control of bleeding, any method) or 45382 (colonoscopy, flexible, proximal to spenic flexure; with control of bleeding, any method), advises Anderson.

Codes for Control of Bleeding 43227Esophagoscopy, rigid or flexible; with control of bleeding, any method 43255Upper gastrointestinal endoscopy with control of bleeding, any method 44366Small intestinal endoscopy not including ileum with control of bleeding, any method 44378Small intestinal endoscopy including ileum with control of bleeding, any method 45317Proctosigmoidoscopy, rigid; with control of bleeding, any method 45334Sigmoidoscopy, flexible; with control of bleeding, any method 45382Colonoscopy with control of bleeding, any method 46614Anoscopy with control of bleeding, any method

Code for Polypectomy or
Control of Bleeding?

The coding dilemma occurs when a gastroenterologist performs both a polypectomy and a control of bleeding procedure at the same time.

If the two procedures are performed in the same area of the gastrointestinal system, Medicare will not reimburse for both procedures, says Anderson. She recommends that gastroenterologists bill for the control of bleeding procedure because it has the higher level of labor intensity.

Peg Hopwood, supervisor of patient accounts for Rockford Gastroenterology, a practice of nine gastroenterologists in Rockford, IL, agrees with Anderson and points out that a polypectomy using hot biopsy forceps in the upper gastrointestinal tract (43250, upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate, with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery) has 6.72 relative value units (RVUs) compared with 9.04 RVUs for 43255. This means that 43255 will be reimbursed at a higher rate than 43250.

Two Procedures in Different Locations

If the polypectomy is performed in a different location than the control of bleeding procedure, a gastroenterologist can bill for both, says Hopwood.

For example, if a polyp is removed by hot biopsy forceps from the duodenum and a control of bleeding is done on an AVM in the stomach, she recommends listing 43255 first because it has the higher RVUs, and then listing 43250 with modifiers -51 (multiple procedures) and -59 (distinct procedural service) attached to it.

Many third-party payers may not require the use of both modifier -51 and -59, acknowledges Hopwood. Medicare carriers will have different policies. Each coder may understand and interpret these coding procedures differently due to variations in policies, she says. Therefore, gastroenterologists should contact these carriers to determine which modifier will be accepted.

In addition, the fee for 43250 will be reduced by the value of a diagnostic upper gastrointestinal endoscopy (43235), so that the gastroenterologist wont be paid for performing the same basic endoscopy. Hopwood also advises including a copy of the operative report with the claim, which is a standard procedure in her practice anytime modifier -59 is used.

Add an Appropriate Diagnosis

An appropriate diagnostic code must be attached to each procedure to ensure proper reimbursement, Hopwood adds. For a polyp in the duodenum, 211.2 (benign neoplasm of duodenum, jejunum and ileum) would be one of several appropriate ICD-9 codes, and 578.0 (hematemesis) might be used for the AVM in the stomach. When billing for two procedures, Hopwood cautions, 578.0 would not be appropriate for both procedures.

If the bleeding is caused by or appears to be caused by the gastroenterologist during the endoscopy, both Hopwood and Anderson agree that theres a good chance Medicare will deny the claim for control of bleeding.

Editors note: Debbie Anderson and Janice Hense, patient account representatives at Rockford Gastroenterology in Rockford, IL, also contributed to this article.