Gastroenterology Coding Alert

Question: We performed an inpatient consultation and decision for esophagogastroduodenoscopy on the same day. The carrier denied our consultation claim and paid for the EGD. Should we have used modifier 59?


Pennsylvania Subscriber

Answer: You can append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to E/M codes when your gastroenterologist provides the service on the same day as a procedure that has a global period of 10 days or fewer (minor procedure).

You would use modifier 57 (Decision for surgery) with E/M codes when the physician decides to perform a major procedure (with a 90-day global) during the E/M service and does so on the same or the following day.

You should use modifier 59 (Distinct procedural service) only if the gastroenterologist performs two or more procedures on the same date in or near the same region.

Suppose that during the EGD the physician finds a duodenal ulcer requiring bipolar cautery to control bleeding and also obtains a biopsy of the stomach to look for Helicobacter pylori. The claim would include 43255 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with control of bleeding, any method) for the EGD with control of bleeding and 43239 (- with biopsy, single or multiple) appended with modifier 59 to indicate a biopsy at a site separate from the bleeding ulcer.