Gastroenterology Coding Alert

Question: The gastroenterologist attempted to perform an EGD with biopsy on a bleeding duodenal ulcer but was unable to perform the procedure because the ulcer was bleeding so severely. He injected epinephrine into the ulcer to control the active bleeding. We reported 43239-22 but we were not paid extra for the modifier 22 addition. What did we do wrong?

Answer: Although the surgery was more complicated than a standard EGD due to the bleeding control, modifier 22 (Increased procedural services) is not the right choice. Instead of reporting 43239-22 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple) and struggling to provide all the additional documentation that the payer will require for a modifier 22 claim, you can accurately describe this session by reporting 43239 for the biopsy and 43255-59 (Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method ; Distinct procedural service) for the control of bleeding.

Although many coders shy away from reporting 43255 for bleeding control when it is achieved via injection, the descriptor for 43255 specifically says “any method,” therefore making the injection method billable using this code. The insurer may still deny the charge due to addressing the same lesion, but this is the correct coding for this scenario, and you can appeal if necessary.

Important point: Remember that the bleeding control doesn’t have to be successful to report 43255. The code doesn’t distinguish attempt from successful hemostasis.