Gastroenterology Coding Alert

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 [...]