Gastroenterology Coding Alert

Rely on Family to Get Through the Multiple Endoscopy Maze

Published on Sat Mar 01, 2003

Do you know how to handle coding for more than one EGD service performed at a single surgical session? Your reimbursement depends on it.

The scenario is familiar, but the coding requirements may not be: Apatient presents for an esophagogastroduodenoscopy (EGD) for gastrointestinal bleeding, and during the exploration the surgeon biopsies and removes by snare technique a lesion in the esophagus and a foreign body from the stomach.

It is common for gastroenterologists to perform more than one service from the EGD endoscopic "family" at one session. And understanding Medicare's multiple endoscopy rule is crucial for receiving appropriate reimbursement for patients requiring multiple upper GI scoping, because if you don't know the rules, you won't get paid for more than one service.

Learn the Differences Between the Claims for Each Rule

The biggest difference between submitting claims for procedures that do and do not fall under Medicare's multiple endoscopy rule is how you should use modifier -51 (Multiple procedures) and modifier -59 (Distinct procedural service). But before you make any decisions about using these two modifiers, you'd better know when to apply each set of rules.

Start by dividing the endoscopy codes into "families of codes," codes for endoscopic procedures that can be performed together with a single pass of the scope, with the main diagnostic code serving as the base procedure code, according to Stephanie Goodfellow, billing supervisor for Mid-America Gastro-Intestinal Consultants in Kansas City, Mo.

The EGD codes (43235-43259) are an example of a family of codes, with 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) serving as the base code.

Some of the common "family members" reported with 43235 include biopsy (43239), PEG tube placement (43246), removal of foreign body (43247), dilation of esophagus with guidewire (43248), balloon dilation (43249), removal of lesion (43250-43251), and control of bleeding (43255).

Medicare's multiple endoscopy payment rule applies to these so-called families of codes, but Medicare's multiple procedures payment rule applies when codes from different families, i.e., codes with different endoscopic base codes, are reported at the same patient encounter, Goodfellow says.

Manage Modifiers -59 and -51

Modifiers -59 and -51 can be required for coding scenarios when either the multiple procedures rule or the multiple endoscopy rule is applicable the key to correctly appending them is to become familiar with the basic guidelines for their use.

Always use modifier -59 when you are trying to convey to the carrier that you know two services should not typically be billed separately, but there is documentation of the reason you are reporting both codes, says Michael A. Ferragamo, MD, FACS, clinical professor of urology at New York State University at Stony Brook. In other words, use modifier -59 to override the bundling of procedures by the National Correct Coding Initiative (NCCI) edits and endoscopies of the same family are often bundled together.

To unbundle two procedures with modifier -59, Ferragamo says, you must have documentation that one of the following circumstances for the second procedure has been met:

It was performed at a different session or patient encounter

It was a different procedure or surgery

It was performed on a different site or organ system

It was performed via a separate incision or excision, lesion or injury or area of extensive injury not ordinarily encountered or performed on the same day by the same physician.

Modifier -51, on the other hand, should be appended to procedure codes that represent services (other than E/M services) that are not components of or incidental to a primary procedure, Goodfellow says. For example, if a gastroenterologist performs a diagnostic EGD and a colonoscopy with biopsy at the same patient encounter, you would code 45380 and 43235-51, sequencing the colonoscopy with biopsy first because it has higher relative value units (RVUs). Modifier -51 is placed on code 43235 because this code has the lower RVUs.

Expect Consistent Pay for Multiple EGDs

Many coders have asked, "Why is it so important that I use modifier -59 rather than modifier -51 for multiple endoscopies?"

Remember, Medicare and private payers that follow Medicare's lead has different rules that correspond to claims for multiple procedures and multiple endoscopies, and the differences, though minor, do impact your bottom line.

When Medicare's multiple endoscopy rule applies, you can expect to be reimbursed 100 percent for the highest-valued procedure, which means you should sequence your multiple EGD codes starting with the procedure with the highest number of relative value units, Goodfellow says. As for the rest of the codes, these EGD services will be paid at the allowable fee minus the base (diagnostic) fee for 43235 then reduced by 50 percent, if they are properly submitted with modifier -59.

Because the payment for 43235 is "built in" to the intervention codes, you can't get paid for the diagnostic portion more than once, which is why you have to subtract this dollar amount from the value amounts of the other procedure performed that day, Ferragamo says. If you were to use modifier -51 rather than -59 on a claim for multiple endoscopies, the carrier might not subtract the fee for the base code before reducing the fee by 50 percent and you could end up having to pay back a carrier. And if you use -51 where -59 is required, your claim may be automatically denied if the services are bundled.

However, if multiple procedures from different endoscopic families are performed and you properly append modifier -51, you will be reimbursed 100 percent of the fee allotted for the procedures sequenced first so you should sequence the highest-paying procedure first and you will receive 50 percent of the value of each subsequent service.