Gastroenterology Coding Alert

Question: Our gastroenterologist performed an EGD with dilation and also biopsy on a patient recently. How should I bill these sessions? Do I need modifiers on these codes? They are not bundled but have been denied in the past without modifier 59 because I was basically told these were in the same “family” and couldn’t be billed together. What should I do?

Arkansas Subscriber

Answer: For the upper GI EGD and guidewire esophageal dilation, you should report code  43248 (Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator[s] through esophagus over guide wire). For the GI EGD with biopsy, you should report code 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple).

You should apply modifier 59 (Distinct procedural service) only when CMS or CPT® normally bundle the procedures, but you need to indicate that the physician performed those procedures at separate (and thus non-bundled) locations. CCI edits do not show bundling issue between these codes. You should ask with your insurance company to provide policy or documentation, why they are denying it. Also, it has been seen that few payers paying these code combination with modifier 51 (Multiple procedures). You can try this as well. You should also ask the payer about the document of modifier preference.

Whether you should use modifiers on your multiple EGD claim will also depend on the situation. You may be tempted to slap modifier 59 on each multiple EGD claim without even thinking about it. However, if you’re not sure that every payer wants modifier 59 on a multiple EGD claim, you cannot be sure that the claim will be clean. Many coders would likely have to attach modifier 59 to 43239. But, for some commercial payers in some states, you may have to attach modifier 59 and modifier 51 (Multiple procedures) to get this combination paid.