Gastroenterology Coding Alert

When part of a claim containing a combination of codes is denied by Medicare, gastroenterologists and members of their coding staff often wonder if they might have gotten more reimbursement by adding modifier -59 (distinct procedural service) to one of the codes. Some of the guesswork surrounding this modifier can be eliminated by studying HCFAs national Correct Coding Initiative (CCI), which uses a system of superscripts to indicate which coding combinations could be separately reimbursable under certain circumstances if modifier -59 is attached to the proper code.

The CCI is a set of published edits or computer instructions to help Medicare payers identify improper claims. The CCI edits, which are published quarterly, give payers and providers more direction on how to bill certain coding combinations, according to Pat Stout, CMC, CPT, an independent gastroenterology coding consultant and president of OneSource, a medical billing company in Knoxville, Tenn.

While the American Medical Associations CPT manual is a good, comprehensive collection of codes and their descriptions, it doesnt give providers any guidance on how to report multiple procedures, she notes.

Unfortunately, busy gastroenterology practices often overlook important information in the CCI. Everyone should review the latest edits as soon as they come out, says Albert Shaw, practice manager at Asher, Kornbluth MDPC, a three-physician gastroenterology practice in New York City. Most people wait three or four weeks; then claims start getting bounced by Medicare. When they try to figure out what has happened, its usually Oh, there was a new CCI edit.

Two Types of CCI Edits

Two lists of edits in the CCI should be reviewed regularly by gastroenterology practices the mutually exclusive edits and the comprehensive/component edits.

Mutually Exclusive Edits: The list of mutually exclusive edits contains coding combinations that HCFA believes cannot reasonably be done in the same session. An example of a mutually exclusive coding combination from the digestive section of the CCI is HCPCS code G0105 (colorectal cancer screening; colonoscopy on individual at high risk) and CPT code 45378 (diagnostic colonoscopy). A gastroenterologist would not perform a screening colonoscopy and a diagnostic one in the same session, explains Stout, who adds that only one of those codes would normally be reported on the medical claim.

Another, more controversial mutually exclusive edit is 43268 (ERCP; with endoscopic retrograde insertion of tube or stent into bile or pancreatic duct) and 43269 (ERCP; with endoscopic retrograde removal of foreign body and/or change of tube or stent), which might be used to report the endoscopic change of biliary stents. Private payers might accept both codes, Stout says, because CPT guidelines say both codes should be reported. An article in the spring 1994 CPT Assistant states that if a stent is already in place, but must be replaced, code 43269 is used to describe the passage of an endoscope to remove the old stent and code 43268 is used to describe the placement of the new stent.

For Medicare forms, however, Stout says that only 43269 should be reported for the stent replacement and removal because HCFA has designated this coding combination as mutually exclusive.

Comprehensive/Component Edits: The list of comprehensive/component edits contains procedures that HCFA considers to be components of a more comprehensive procedure. These component codes are bundled into the comprehensive code and are not separately reportable unless the component procedure is separate and distinct.

There is a standard template of component codes that are bundled into many of the endoscopy codes used in gastroenterology. Either anesthesia code 00740 (anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum) or 00810 (anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum) is usually a component of most gastrointestinal endoscopy procedures and cannot be separately reimbursed, as are intravenous injections (36000, 36005 and 36010-36015), venipunctures (36410), IV infusion therapy (90780-90781), injections (90782-90784) and pulse oximetry (94760-94761).

In addition to the standard template of edits, procedures within the same coding family are often bundled. An example of this, according to Stout, are codes 45382 (colonoscopy; with control of bleeding) and 45385 (colonoscopy; with removal via snare technique). HCFA considers control of bleeding to be an inherent component of every polypectomy, including those done by snare technique, and lists code 45382 as a component of comprehensive code 45385. This is done to prevent gastroenterologists from reporting an additional control-of-bleeding procedure when they attempt to control bleeding brought on by the polypectomy.

Overriding a CCI Edit

When a coding combination is listed as either a mutually exclusive or comprehensive/component edit, the general rule is that both codes cannot be reported separately. However, HCFA also uses superscripts in the CCI to indicate edited coding combinations that can be reported separately under the appropriate circumstances.

Two CCI superscripts (also known as Correct Coding Modifiers [CCM]) are commonly used when coding for gastrointestinal procedures.

A CCM of 0 indicates that it is never acceptable to bill these procedures together, according to Shaw. An example of a coding edit that has a CCM of 0 is 43235, EGD (upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), which is the comprehensive code, and 43200 (esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), the component code.

A CCM of 1 indicates that these codes are considered bundled but can be billed separately under certain circumstances. This means that it is possible to override the CCI edit, Shaw explains.

In the previously cited coding combination of codes 45385 and 45382, the control-of-bleeding component code (45382) has a CCM indicator of 1. This means the combination is separately reimbursable under certain circumstances, such as if the procedures were performed in different parts of the colon. For example, if the gastroenterologist removes a polyp in one area of the colon and then uses a cautery to control the bleeding of an arteriovenous malformation in a different part of the colon, both codes can be reported.

Use Modifier -59 to Override CCI Edits

Modifier -59 designates separate procedures and will be the primary modifier used by gastroenterology practices to override CCI edits with a CCM indicator of 1, according to Stout and Shaw. An article in the July 1999 issue of CPT Assistant states that the modifier indicates that a procedure is not considered a component of another procedure, but a distinct, independent procedure, such as a:

different session or patient encounter;
different site or organ system;
separate lesion; or
treatment of a separate injury (or area of injury in extensive injuries).

Modify the Component Code

There is often confusion over which code in the combination should have the modifier attached to it. The Medicare Carriers Manual states, the secondary, additional, or lesser procedure[s] or service[s] must be identified by adding the modifier -59. In the polypectomy/control-of-bleeding example, many gastroenterology coders would attach the modifier to the polypectomy code, 45385, because it has a lower relative value unit (RVU), which they interpret to mean it is the lesser procedure.

Stout, however, interprets the phrase lesser procedure[s] or service[s] to mean the component code, which does not always have a lower RVU than the comprehensive code. You always add modifier -59 to the code that would otherwise be denied, Stout explains. Its the control-of-bleeding procedure that is usually bundled into the other endoscopic procedures and not the other way around, so that would be the procedure that Medicare and other payers would tend to deny.

Other Modifiers Will Override Too

Modifier -59 cannot be attached to E/M codes. Modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is usually used to override a CCI edit for E/M codes.

While modifiers -59 and -25 will be the primary ones used for gastrointestinal procedures and services, other modifiers that can override a CCI edit include modifier -58 (staged or related procedure or service by the same physician during the postoperative period), modifier -78 (return to the operating room for a related procedure during the postoperative period), and modifier -79 (unrelated procedure or service by the same physician during the postoperative period).

Not All Bundled Services Are Listed

Although the CCI can help point out what coding combinations are reimbursable separately and when modifier -59 can be used to override a coding edit, the edits have shortcomings. It is not possible for the CCI to list all the possible component codes for every procedure. Conscious sedation (99141) during an endoscopy, for example, is not separately reimbursable by Medicare, but is not listed as an edit.

Its part of HCFAs global surgery policy not to reimburse for anesthesia provided by the physician during endoscopies, Shaw explains, but its not included in the list of edits.

Conscious sedation is just one of many services performed frequently by gastroenterologists that are considered so integral to a procedure that it is impractical and unnecessary to list every event common to all procedures of a similar nature as part of the narrative description for a code, according to the introductory notes to the CCI.

Other generic services classified as integral to standard medical/surgical services include:

cleansing, shaving and prepping of skin;

draping of patient, positioning of patient;

insertion of intravenous access for medication;

sedative administration by the physician performing the procedure;

local, topical or regional anesthetic administered by the physician performing the procedure;

surgical approach, including identification of anatomical landmarks, incision, evaluation of the surgical field, lysis of simple adhesions, isolation of neurovascular, muscular (including stimulation for identification), bony or other structures limiting access to the surgical field;

preoperative, intraoperative and postoperative documentation, including photographs, drawings, dictation, transcription; and

surgical supplies, unless excepted by existing HCFA policy.

Stout says the CCI does not take into account all the different coding combinations that could describe a single comprehensive code. Report an EGD with biopsy, with the comprehensive and bundled code 43239 (EGD with biopsy), Stout explains. However, the same procedure could be incorrectly reported by unbundling the comprehensive code into two component codes, 43235 (EGD) and 43600 (biopsy of stomach; by capsule, tube, peroral [one or more specimens]). This problem can be avoided by using the most comprehensive code possible to describe the procedures and services that were performed.

Inconsistent edits are confusing. Codes 43204 and 43205 are bundled as mutually exclusive codes in the CCI. However, the same procedures done with an EGD (43243 and 43244) are not bundled.

There isnt always any logic to the CCI system. Stout admits. You cant really learn the edits or memorize them. You just have to keep looking them up.

The latest version of the CCI edits can be ordered from NTIS by calling 1-800-363-2068 or by ordering online at www.ntis.gov/product/correct-coding.htm.