Gastroenterology Coding Alert

Question: Our GI physician performed EGD with polyp ablation and also polyp removal by snare technique. We reported 43270 and 43251 but the claim was denied. Should we have used a modifier?

Texas Subscriber

Answer: The answer may depend on more details from the procedure notes. When your gastroenterologist performs other EGD procedures during the same session in which they perform an ablation, you will need to pay attention to the National Correct Coding Initiative (NCCI) edits.

Some of the EGD procedures that run into edits with 43270 (Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)) include:

• 43250 (Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps)
• 43251 (…with removal of tumor(s), polyp(s), or other lesion(s) by snare technique)
• 43255 (…with control of bleeding, any method)

All the above-mentioned edits carry a modifier indicator of “1,” which means that you can separate the codes with a suitable modifier such as 59 (Distinct procedural service). So if, as in your situation, the gastroenterologist performs removal of a polyp by ablation and removal of another polyp by snare technique in a different location, you can report both 43251 and 43270. You will have to append modifier 59 to 43251. The report should make it clear that these were different lesions in different locations.

Caveat: If your gastroenterologist ablates a tumor or polyp and, during the procedure, encounters ablation-related bleeding and controls it with a plasma coagulator, then you cannot report 43255 for the bleeding control. In this case, the bleeding control is part of the polyp removal procedure and therefore cannot be reported separately. But if the polyp removal and the bleeding control were in two different sites, you can use the modifier to separate the codes and report them separately. Be sure to provide documentation supporting your claims when you do so.