Gastroenterology Coding Alert

Question: Our physician just performed an EGD with biopsy and control of bleeding for a Medicare patient. Medicare paid on 43239-59 but denied 43255 for lack of modifier. In a second case, our physician performed the EGD on the same day for an inpatient hospital subsequent care 99232. Medicare paid the 43255 but denied 99232. What modifier should have been used for the 99232 done same day as procedure?

Oklahoma subscriber 

Answer: In the first scenario, 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple) with modifier 59 (Distinct procedural service) was billed with 43255 (Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method). You should bill modifier 59 with 43255 and not the 43239, according to the National Correct Coding Initiative (CCI) edits. Please keep in mind that when bleeding occurs as a result of an endoscopic procedure (biopsy, other removal, dilation, etc.), you should not report the control of bleeding separately during the same operative session. So, check your documentation to be sure that the bleeding was not as a result of the biopsy procedure.

In the second scenario, you billed a 99232 (Subsequent hospital care,per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components:…) in addition to 43255. The 99232 is inclusive to the 43255 unless the visit is significant and separately identifiable. You may append a modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service) to the 99232 if the following criteria are met:

• The E/M occurs on the same day as the surgical procedure
• The procedure following the E/M is minor (has a zero or 10-day global period)
• The E/M service is both significant and separately identifiable from any inherent E/M component, and that the procedure involves the same physician (or one with the same tax ID) provides the E/M service and the subsequent procedure.

Note: The diagnosis associated with the E/M service can be the same as the diagnosis associated with the same-day procedure, which means that the E/M prompted the follow-up procedure. Or the diagnosis associated with the E/M service can be different than the diagnosis associated with the same day procedure, meaning that the E/M was for a significant problem unrelated to the procedure.