Gastroenterology Coding Alert

Question: One of our surgeons encountered some challenges while attempting to perform a banding procedure for esophageal varices. The surgeon unintentionally induced active variceal bleeding during the procedure. The surgeon then carried out sclerotherapy to manage the bleeding. The dilemma now is whether to document the banding procedure, the sclerotherapy, or both?

AAPC Forum Participant

Answer: You should report 43244 (Esophagogastroduodenoscopy, flexible, transoral; with band ligation of esophageal/gastric varices) with modifier 53 (Discontinued procedure). You should get some reimbursement for the service, but the amount will probably vary from payer to payer.

“Remember that modifier 53 may be applied any time after anesthesia has been administered, though most surgeons do not choose to bill until the procedure has actually been attempted,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, product manager, MRO, in Philadelphia. The modifier does not need to be applied if the banding was actually completed but bleeding occurred anyway.

You cannot bill for the sclerotherapy (43243, ... with injection sclerosis of esophageal/gastric varices) because Medicare and most private insurers have a “you-break-it-you-fix-it” policy. For the same reason, you wouldn’t bill for the control of bleeding (43255, … with control of bleeding, any method).

According to the National Correct Coding Initiative (NCCI), when a complication occurs during an operative session, you should not bill for a separate service to treat that complication. The NCCI guidelines emphasize that the treatment of complications should be considered an integral part of the primary procedure and should not be separately coded or billed.