Gastroenterology Coding Alert

Question: A patient had an EGD with injection and the provider used bicap cautery to endoscopically control bleeding from AVMs and performed biopsy on suspected masses. I billed Medicare 43255 first CPT® code and 43239-59 second CPT® code, however, Medicare added modifier 59 to 43255 and 59 plus 51 to second CPT® 43239. What should I do?

Oklahoma Subscriber 

Answer: If you check CCI edits, 43255 (Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method) is a column 2 code for 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple) and requires the use of a modifier. 

According to your information, the physician used bicap cautery to endoscopically control bleeding from AVMs. This control may be achieved using several endoscopic methods, including laser therapy, electrocoagulation, rubber band ligation or injection of the bleeding vessel with clerosants, ethanol or adrenaline. According to the CPT® manual, the description confirms that the appropriate code assignment for the facility component is 43255. 

As the provider also took some biopsies from several areas of the stomach, the description confirms that the appropriate assignment, for both the facility and professional components, is code 43239. 

However, the modifiers you attach on this claim will depend on your payer. Many coders would likely have to attach modifier 59 (Distinct procedural service) to 43239, but in Indiana, for example, in order to get this combination paid, you have to attach modifier 59 and modifier 51 (Multiple procedures) for [many] commercial payers. For Medicare, you have to just attach modifier 51. In cases of appeal, if you explain the use of each modifier, the payer understands the claim better and the appeal stands a better chance of acceptance. You should only attach modifier 59 if the procedures are bundled, and you need to show that there were two separate procedures performed at two separate locations.

Therefore, the modifiers required by the payer are not universal and you should check payer guidelines to determine if they require a modifier when billing this combination of codes. If Medicare added these two codes on your explanation of benefits (EOB), more than likely this is the way that they would like for you to bill these codes.