Gastroenterology Coding Alert

Use mod -59 when coding procedures not normally reporting together

When your gastroenterologist performs two procedures from the same endoscopic family, do you always report only one code? If the gastroenterologist performs two surgeries on the same day, do you assume that the lesser procedure isn't reportable?

If you answered "yes" to either of these questions, you may not be taking advantage of all the situations when you can use modifiers -59 and -51. Read on for more information on these modifiers to help you when reporting related codes on the same claim.

Use Mod -59 When Codes Are Close

Gastroenterology coders use modifier -59 (Distinct procedural service) to identify procedures that are distinctly separate from any other procedure or service the physician provides on the same date.

In general, coders append modifier -59 to procedure codes when the physician:
 

sees a patient during a different session;

treats a different site or organ system; or

treats a separate injury.

In gastro offices, this modifier "is not usually used during office visits," says Linda Parks, MA, CPC, CMC, CCP, coding specialist at GI Diagnostics Endoscopy Center in Marietta, Ga. "It's used when multiple procedures in the same endoscopic family are performed at the same time."

Example 1: Let's say the gastroenterologist performs a colonoscopy with a cold biopsy and removes a separate polyp via snare technique.

You should:

report 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s] or other lesion[s] by snare technique)

attach modifier -59 to CPT 45380 ( ... with biopsy, single or multiple). The modifier shows the carrier there were two different sites treated.

"If these codes were billed without a modifier, 45380 could be bundled into 45385 [by the insurance carrier]," Parks says.

Example 2: The gastroenterologist performs an upper gastrointestinal endoscopy (EGD) with balloon dilation of the esophageal stricture and an EGD with biopsy of a gastric ulcer.

You should:

report 43249 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with balloon dilation of esophagus [less than 30 mm diameter])

attach modifier -59 to 43239 ( ... with biopsy, single or multiple). The modifier shows the carrier there were two different procedures performed, even though they were both EGDs.

Pay Attention to Code Order

Make sure you know which code you are attaching modifier -59 to, or you could lose out on money. "The modifier should always be placed on the code with the lower RVU [relative value unit], or the code that will be denied to National Correct Coding Initiative (NCCI) edits," Parks says.

Not sure about NCCI? If you're stuck on whether you should bill codes with the -59 modifier, check the NCCI edits. If the codes you are reporting have indicators of "1" next to them, this means you may be able to append an appropriate modifier to bypass the edit. If the code has an indicator of "0," you cannot bypass the edit. The NCCI edits change quarterly, so be sure to keep abreast of all updates.

Time Saver: Increase your mod -59 reimbursement rate by using it only when absolutely necessary -- many payers do not require the use of a modifier in multiple-procedure scenarios. Check with your individual payer to see if the -59 modifier is necessary when reporting multiple-procedure claims.

However, don't be afraid to use the -59 modifier if you have no recourse -- just make sure it is "the modifier of last resort."

Use Mod -51 for Multiple Procedures

When your physician treats a patient with multiple injuries requiring multiple procedures, you would include modifier -51 (Multiple procedures) on your claim.

Mod -51 is "an informational-type modifier ... for use on the second, third, etc. surgical procedure performed on the same day," says Barbara J. Girvin Riesser, RN, CCS, CCS-P, CPC, of Medical Management Resources in Kansas City, Mo.

For example, when a gastroenterologist extracts stones, he often uses removal and destruction methods in the same session.

When your gastroenterologist provides both removal and destruction procedures in the same session, you may be able to:

report 43264 (Endoscopic retrograde cholangiopan-creatography [ERCP]; with endoscopic retrograde removal of calculus/calculi from biliary and/or pancreatic ducts)

append modifier -51 to 43260 ( ... diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]). The modifier shows the carrier that the gastroenterologist performed removal and destruction procedures in the same session.

Check with your carrier first: Attaching modifier -51 to 43260 in the above example may not work with all insurance carriers.

Make a preemptive strike against denials by contacting your insurance carrier and asking the representative which method they would prefer when reporting multiple surgical procedures.

Then, make a note of each carrier's policy on coding multiple procedures, so you can reference it quickly the next time a -51 modifier issue arises.

Remember: Although reimbursement rates for codes with modifier -59 attached vary by payer, expect half the normal reimbursement for codes with modifier -51 attached. (Most insurance companies have adopted Medicare's policy paying 50 percent for codes with modifier -51 attached.)