Gastroenterology Coding Alert

Overuse of modifier -59 (Distinct procedural service) raises red flags and invites audits, but knowing some typical gastroenterology scenarios in which to use it will steer you to the path of reimbursement success.

When a gastroenterologist biopsies and removes the same polyp, the Correct Coding Initiative bundles the procedures, says Staci Jordan, CPC, CCS-P, reimbursement analyst for the University of Oklahoma Health Sciences Center in Oklahoma City. However, if a polyp is biopsied and a separate lesion is removed, you may report both procedures.

For instance, a gastroenterologist removes one polyp using hot biopsy forceps and biopsies a separate lesion using cold forceps. Assign 45384 and CPT 45380 -59-51, Jordan says.

For the hot biopsy removal, report 45384 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery). For the biopsy, use 45380 ( with biopsy, single or multiple).

"Append modifier -59 to the lower relative value unit (RVU) procedure, no matter what was done second," says Barbara Cobuzzi, MBA, CPC, CPC-H, president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. The removal (45384) is a higher-valued procedure (7.07 facility RVUs) than the biopsy (45380, 6.7 facility RVUs). So, append modifier -59 to 45380 to indicate the removal occurred at a separate site from the biopsy.

"You need to let the insurance know that you are not trying to bill for the biopsy of the same polyp twice," Jordan says. "Modifier -59 on 45380 tells the payer that two separate distinct, procedures were performed one polyp was removed using hot biopsy forceps, and a separate lesion/polyp was biopsied using cold forceps. However, if you biopsied the polyp using cold forceps and then subsequently removed that same polyp using hot biopsy forceps, you can only charge for the hot biopsy."

In addition, Jordan adds modifier -51 (Multiple procedures) to the biopsy code to indicate multiple procedures. Although coding experts and the American College of Gastroenterologists advocate this method, the CCI does not require the multiple-procedures designation.

The CCI bundles biopsy codes (43202, 43239, 44361, 45331, 45380) with removal by hot forceps (43216, 43250, 44365, 45333, 45384) and the removal by snare technique codes (43217, 43251, 44364, 45338, 45385). These edits contain a superscript of 1, meaning that under certain situations modifier -59 is appropriate to break the bundle. The modifier by definition makes both procedures separate, not incidental. Since no clear rules exist, contact your individual carriers for their policies.

"Modifier -59 is the modifier of last resort," Jordan says. "When another already-established modifier is appropriate it should be used rather that modifier -59," states CPT. "Only if no more descriptive modifier is available, and the use of modifier -59 best explains the circumstances, should modifier -59 be used."

Many experts recommend using modifier -59 only if the procedures are bundled in the CCI. Otherwise, they advise using a more appropriate modifier, such as -51. Unfortunately, carrier preferences are not as straightforward. For instance, a gastroenterologist performs an ERCP (endoscopic retrograde cholangiopancreatography) with lithotripsy and stone removal. The basic coding is relatively simple. For the lithotripsy, report 43265. For the stone removal, assign 43264.

However, deciding which modifier to use is more troublesome. Because the CCI does not bundle these procedures, some experts advise coding both procedures with modifier -51 on the lower-valued procedure the stone removal (43264, 12.89 RVUs versus 14.43 RVUs for 43265).

But many experts use modifier -59 to report procedures in the same endoscopic family. They reason that the procedures are related, thus warranting modifier -59 to explain that the procedures are different surgical procedures. "The majority of the carriers will not pay on the -51 modifier; they will pay only on the -59," says Linda Parks, MA, CPC, lead coder at Atlanta Gastroen-terology Associates. "Check with your payers to see which modifier they request using."

"According to coding rules, the procedures should be paid on the multiple-procedure fee reduction schedule or in full based on the procedure code," says John Lavere, MBA, CPC, director of compliance, Charlotte, N.C. "Medicare and private payers will vary based on their multiple fee schedule reduction formula. Additionally, some payers either don't recognize or disregard modifier -59. Thus, it is key to follow up on your evaluation of benefits to ensure proper reimbursement." Make sure to file the full fee and allow the carrier to determine the adjustment.

"The operative notes should always clearly indicate the separate/distinct procedure," Lavere says. "This will help in the appeals process," which may be inevitable.

"A majority of insurance companies now use Claim Check as their editing system, so anytime any of the indented scope codes are billed together they are automatically denied as incidental," Jordan laments. To get the claims paid, appeal with documentation and a clear letter stating that the procedures are separate, and the payer should reimburse both. Even so, some payers will still not pay, Jordan concedes.