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 $500.

Johnson-Hurley would first list an unmodified 45384 (hot biopsy forceps) with a price of $600. Then she would list 45385 (snare technique) without a modifier, and a price of $300 (reduced by $200, the price of the basic, diagnostic colonoscopy, 45378).

However, Schraffenberger disagrees and is leery of price adjustments. She goes by the maxim of keep fees consistent, and believes that gastroenterologists should leave their standard fee on [the claim] and let the payer reduce it, because having the same codes with different prices attached may change their Medicare profile, which could result in decreased reimbursement in the future.

Coding for Two Distinct Procedures

Another situation where theres a choice between the -51 modifier and fee adjustments is when a biopsy and a colonoscopy with polyp, tumor or lesion removal are performed as two distinct procedures.

Biopsies during a colonoscopy should not be billed separately with code 45380 (colonoscopy, with biopsy, single or multiple) when the mass that was biopsied was removed in the same session. That biopsy is already a component of colonoscopy codes 45383, 45384 and 45385.

If a gastroenterologist does a biopsy on something that
is not removed later in the procedure, then the biopsy can
be billed separately. Schraffenberger cites as an example a polyp, tumor or growth that is too large to be removed at that time, but the gastroenterologist feels the need to have it examined. In this case, she suggests listing the colonoscopy procedure (45383, 45384 or 45385) first, because it has a higher RVU, then the biopsy code (45380) with the -51 modifier appended to it.

Hurley would list the unmodified colonoscopy procedure (45383, 45384 or 45385) first, followed by the biopsy code (45380) and reduce the fee for the biopsy by $200the value of the diagnostic colonoscopy.

To differentiate the two procedures to the carrier, Hurley would use two separate ICD-9-CM codes. For example, code 211.3 (benign neoplasm of the colon, including appendix, cecum, ileocecal valve, and large intestine NOS) might be used to indicate the discovery of a polyp in the traverse right colon, and code 211.4 (benign neoplasm of other parts of the digestive system; rectum and anal canal) for one found in the rectosigmoid junction.

Avoid Modifier -51 Misuse

Both women agree that there are several situations when the -51 modifier is frequently misused, such as to claim extra reimbursement for removing multiple polyps.

The colonoscopy codes 45383, 45384 and 45385 are all worded to include the phrase tumor(s), polyp(s), or other lesion(s). Hurley interprets this to mean that if the same technique is being used, you can only bill onceeven if the polyps are in two different locations.

She would never use a -51 modifier to signify that during the same procedure another tumor was removed from a different location, though she adds that some local carriers may be paying for that.

A carrier might make an exception, Hurley believes, and give extra reimbursement if an unusually large number of polyps were removed. To make a claim in that particular case, the -22 modifier (unusual procedural services) should be appended to the colonoscopy code, she explains. The claim should also include a copy of the operative report and separately state the amount of extra time and care that was provided. If the modified claim is honored, she estimates that a gastroenterologist could receive a combined total of 120 to 135 percent of the standard reimbursement allowed.

Hurley sympathizes with the confusion that gastroenterologists often have when trying to get reimbursed for colonoscopies and says that this often boils down to a carrier issue.

Rather than just picking the -51 modifier approach or adjusting procedure prices, and possibly going through a round of denials from a payer, gastroenterologists should first contact their local carrier to find out which method they prefer. This does not necessarily solve every claim problem, but it can certainly help reduce denials.