Gastroenterology Coding Alert

Although your gastroenterologist may justify modifier 22 on procedures involving excessive blood loss, you may be better off simply reporting a separate code -- or even critical care -- for control of bleeding.

If the gastroenterologist uses epinephrine injection for control of bleeding during an upper GI endoscopy, you might call on 43255 (Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; with control of bleeding, any method) -- in addition to the code for the primary procedure -- to describe the physician's effort.

Example: The doctor injects epinephrine into a duodenal ulcer to control active bleeding during endoscopy with biopsy (43239, ... with biopsy, single or multiple).

In this case, if the control of bleeding adds significant physician effort, you may be tempted to report 43239 appended with modifier 22 (Increased procedural services).

Better way: Instead of reporting 43239-22 and struggling to provide all the additional documentation that the payer will require for a modifier 22 claim, you can accurately describe this session by reporting 43239 for the biopsy and 43255 for the control of bleeding. Code 43255 accurately describes control of bleeding by "any method," including injection.

"I agree that it's better to report the epinephrine injections with 43255 rather than applying modifier 22" to the primary procedure, says Doug Williams, CPC, business office manager for Consultants in Gastroenterology SC Endoscopy Center in Columbia, S.C.

Keep in mind: On your claim, you'll report 43255 with modifier 59 (Distinct procedural service) and 43239. Without the modifier, payers will assume that the biopsy (or physician) caused the bleeding and bundle 43255 into 43239.

You cannot report control of bleeding if the gastroenterologist causes the bleeding, says Chris Harvey, LPN, coder/charger for Visionary Enterprises Inc. in Indianapolis. You should call on control-of-bleeding codes only "when treatment is required to control bleeding that occurs spontaneously, or as a result of traumatic injury (noniatrogenic), and not as a result of another type of operative intervention," according to CPT Assistant September 1996.

In some cases, the patient's condition might necessitate critical care (99291, 99292) instead of a procedure code with modifier 22.

Example: The physician plans to perform an upper GI endoscopy, but the patient has gastrointestinal bleeding so severe that the physician must suspend the endoscopy and spend 40 minutes lavaging blood from the gastro-intestinal tract before continuing.

In this situation, you should report critical care code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes).

Don't overdo it: You shouldn't report a critical care code for a normal control-of-bleeding situation or if the physician causes the bleeding. In this example, however, the patient meets the definition of being critically ill because the severity of the bleeding could be a potentially life-threatening deterioration in the patient's condition.