Gastroenterology Coding Alert

Question: We are having a problem with insurance companies that deny consultations and hospital care after procedures. What is the correct modifier to use?

Anonymous NJ Subscriber

Answer: If the procedure has a 0- or 10-day global period, modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) should be used, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant in North Augusta, SC. For example, a patient presents coughing up bright red blood. He or she is admitted for further evaluation and monitoring, and an EGD with control of bleeding (43255) is performed. Modifier -25 is attached to the appropriate level hospital admission code (99221-99223).

In another instance, a patient unable to feed has a percutaneous gastrostomy tube placed (43750), which has a 10-day global period. Three days after the placement, the patient begins vomiting and diarrhea. The gastroenterologist determines that the patient is suffering from a viral gastroenteritis (008.8) and prescribes treatment. An appropriate evaluation and management (E/M) code may be submitted (99211-99215 in the office setting or 99231-99233 in the inpatient setting) with a -24 modifier (unrelated E/M service by the same physician during a postoperative period) to represent an E/M service provided for an unrelated problem during the postoperative period, explains Callaway-Stradley.

Each of these modifiers has specific guidelines that may vary by insurance company. Before submitting any E/M service for reimbursement during the global period of a procedure (day of the procedure or after the procedure), verify that you have met the requirements for the modifier in question with your patient's insurance carrier.