Gastroenterology Coding Alert

Question: Some insurance companies bundle surgical codes such as 45380 (Colonoscopy; with biopsy, single or multiple) and 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy) and only pay for the first code, leaving the office to write off the second. I have argued that they are two separate codes with separate diagnoses, done at two separate "ends" so to speak. They still refuse. How can I maximize payment without making the patient come back two separate days to the hospital?

New Jersey Subscriber

Answer: Insurance companies are free to bundle procedures, meaning they are not mutually exclusive. One procedure is thought of as being part of the other one, therefore not qualifying as billable. This means that one procedure cannot be done without its pair. However, it may be possible to get around this automated denial. You should ask your insurance company if it is possible to use a modifier to differentiate between services provided. The bundles in the CCI edits provide for these circumstances. For instance, modifier -59 (Distinct procedural service) can be used to maximize reimbursement.

If you have tried using modifier -59 and the carrier does not accept this, you should make sure the codes you use meet the criteria for being medically necessary for the diagnosis. For example, Empire Medicare Services of New York lists a myriad of ICD-9 codes that prove medical necessity for colonoscopies, such as V10.00 (Personal history of malignant neoplasm, gastrointestinal tract, unspecified) and 042 (HIV disease). Chronic abdominal pain, hemorrhoids, acute limited diarrhea, and upper GI bleeding with an upper GI source are a few of the reasons that coverage is denied. It is important to document properly all your claims to receive optimal benefits.

In the end, if the insurance company insists that codes will be bundled even beyond normal CCI edits, the practice may have no alternative but to write off the charges if the physician's contract with the insurance company allows the carrier that power. It is medically unnecessary and probably unethical to make the patient come back for two separate procedures.