Gastroenterology Coding Alert

Colonoscopy is one of the most common procedures performed in gastroenterology practices. CPT 45380 (colonoscopy with biopsy) is the tenth most frequently used code by gastroenterologists to bill Medicare, according to a recent analysis by the American Gastroenterological Association (AGA). Despite the frequency of the procedure, however, many gastroenterologists still have questions on how to code for colonoscopies when multiple techniques are used to remove tumors, polyps or lesions.

Sharon Ely, office manager of U.P. Digestive Disease Associates, a facility with four gastroenterologists in Marquette, MI, wonders why they havent been reimbursed when two different methodshot biopsy forceps (45384) and the snare technique (45385)are both used to remove polyps during a single colonoscopy. Each technique was coded separately and no modifiers were used.

Two coding experts say there are two possible approaches to Elys reimbursement dilemma. One involves the use of the -51 modifier (multiple procedures); the other adjusts the actual fees that the gastroenterologist is charging the carrier.

Append Modifier -51

The procedure is performed using different techniques and different instruments, so its okay to bill for extra, she says.

The -51 modifier should be appended to the technique with the lower relative value unit (RVU), which in this case is the snare technique (45385), according to Lou Ann
Schraffenberger, MBA, RRA, CCS, clinical data manager for Advocate Health Care in Chicago and chair-elect of the Society of Clinical Coding.

The technique with the higher RVU, in this case the hot biopsy forceps (45384) should be listed first, advises Schraffenberger. Full reimbursement will not be paid for the technique with the lower RVU, because modifier -51 will cause a reduction for that procedure.

Payment will be reduced by the value of a basic, diagnostic colonoscopy (45378) because the gastroenterologist is doing only one insertion.

Fee Adjustments

Alternately, in the same situation, Jaci Johnson-Hurley, CPC, vice president of client services at Coding & Documentation Specialists, a consulting firm serving several gastroenterologists and located in Glen Allen, VA, would forgo using the -51 modifier and directly adjust the gastroenterologists fees.

While acknowledging that some people may use a -51 modifier to accomplish the same thing, she feels that adjusting the price of the service by subtracting the value of the basic colonoscopy has been the most effective way for
her clients to receive reimbursement from their local
Medicare carrier.

Johnson-Hurley recommends listing the technique with the higher RVU first and then adjusting the fee of the one with the lower RVU. In this example, the unadjusted reimbursement allowed for a basic, diagnostic colonoscopy (45378) is $200. The unadjusted reimbursement allowed for a colonoscopy with hot biopsy forceps (45384) is $600 and with the snare technique (45385) is [...]