Gastroenterology Coding Alert

Question: My gastroenterologist performed a stomach biopsy on a patient, which also required an epinephrine injection to control bleeding in a duodenal ulcer. The injection and the biopsy were performed in separate areas. Can I report both procedures?

Missouri Subscriber

Answer: You are correct in reporting the control-of-bleeding injection and the biopsy, as long as the polyp and the injection site are in different locations. Report the biopsy with 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple). Use 43255 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with control of bleeding, any method) to report the shot of epinephrine, with modifier -59 (Distinct procedural service) appended.
 
Although 43255 has a higher relative value unit than 43239, it is often denied by payers because it is bundled into the biopsy. The control-of-bleeding procedure is typically viewed as part of other endoscopic procedures - not the other way around. The injection should be reimbursed at 100 percent of its allowed fee because it is the higher-valued procedure. Payment for the biopsy code will be the difference between it and its base endoscopic code.
 Gastroenterologists cannot charge separately for the injection of epinephrine. When the procedure takes place in a hospital, you can bill for the epinephrine. But in other settings, the cost of the epinephrine is included in the fee.