Gastroenterology Coding Alert

Patients sometimes develop complications after an endoscopy is performed that requires a second endoscopy or hospitalization. If these complications occur on the same day as the original endoscopy, the gastroenterologist may face some Medicare coding dilemmas. By correctly using modifiers, gastroenterologists and their coders can achieve reimbursement for the hospital admission when Medicare looks askance at reporting an E/M service on the same day as an endoscopy. Further, modifier use will help gastroenterology professionals avoid having Medicare reduce reimbursement for the second endoscopy with the application of its multiple endoscopy or bundling rules.

Service Must Fall Outside the Global Package

Before deciding how to report these encounters and procedures, gastroenterologists must determine whether a postoperative service is separately reportable or a part of the global package for the initial endoscopic procedure. Many postoperative services performed after an endoscopy are not eligible for separate reimbursement. Things like recovery from sedation and checking of vital signs are related to the endoscopic procedure and are part of the global surgical package, says Carol Pohlig, CPC, BSN, RN, a reimbursement analyst for the Hospital of the University of Pennsylvania department of medicine in Philadelphia, where more than 30 gastroenterologists practice.

Another routine postoperative activity not separately billable is time spent in the observation room of an endoscopy suite. For a routine endoscopy done in an outpatient facility, the patient may spend 60 to 90 minutes in observation after the procedure, says Delbert Chumley, MD, a gastroenterologist in San Antonio, and a trustee for the American College of Gastroenterology. Also, the gastroenterologist may talk to the patient about the findings, his or her evaluation and a plan of treatment. This is all part of the global package and considered regular postoperative care.

Postoperative Complications Require Action

Some minor complications that are treatable in the observation room of the endoscopy suite are also part of the global package. If the patient is vomiting in the observation room of the endoscopy suite, you keep him or her in observation until he or she is feeling better, but you dont bill for that, Chumley say. If the patient starts vomiting and goes into shock, then thats above and beyond regular postoperative care.

If the gastroenterologist becomes involved in the medical management of complications that are not part of the routine followup care, he or she is beyond the global surgical package. Once you have identified that the patient has bleeding, fever or infection, and are giving care to those complications, then that medical management is outside of the global package, Pohlig says.

If the gastroenterologist has given orders to put the patient on hydration therapy after developing pancreatitis from an endoscopic retrograde cholangiopancreatography [ERCP], for example, the problem has been identified and is being managed. When you have to do another endoscopy because of complications from the initial endoscopy on the same day, that is also considered subsequent care and may be separately billable, Pohlig says.

Control of Bleeding Is Difficult to Get Reimbursed

Not all same-day followup endoscopies may be reimbursed, however, especially if the complication is gastrointestinal bleeding. For example, a patient who initially had a colonoscopy with snare technique (45385) may have to undergo a colonoscopy with control of bleeding (45382) to stop postoperative gastrointestinal bleeding. Modifier -78 (related procedure during the postoperative period) should be attached to the control of bleeding procedure to indicate that it was done in a different session from the initial endoscopy, Pohlig says. Depending on the particular requirements of the payer, modifier -59 (distinct procedural service) may also have to be attached to the control of bleeding procedure because 45382 is bundled into the initial colonoscopy (45385) in the National Correct Coding Initiative (CCI).

According to the Medicare Carriers Manual, section 4824(C), procedures with zero global days, including most endoscopies, that are billed with modifier -78 should be paid in full because these codes have no pre-, post- or intraoperative values. However, Pohlig warns gastroenterologists to keep in mind that some payers view modifier -78 as an admission that he or she caused the complications and that the procedure is being reported for information. Also, some payers may require that a different modifier be used in these situations. Therefore, gastroenterologists should contact their local payers for specific coding and reimbursement instructions.

Even when a different modifier is used, reimbursement for any followup endoscopies performed to control bleeding may be difficult to receive. Regardless of the modifier used, a control of bleeding code may not get paid because the payer believes that the gastroenterologist caused the complication by nicking the patient during the initial endoscopy, Pohlig explains.

Use Modifier -76 for Repeat Procedures

When a followup endoscopy is performed because of other types of complications, the gastroenterologist stands a better chance of reimbursement and should use a different modifier. Lets say that a patient who initially has an esophagoscopy with stent placement [43219] because of problems with swallowing [787.2, dysphagia] has a complication where the stent occludes and malfunctions, Pohlig explains. The gastroenterologist may want to repeat the procedure so that he or she can attempt to place another stent. In this case, 42319 would be reported a second time on the claim with modifier -76 (repeat procedure by same physician) attached. A different diagnosis code, such as 996.59 (mechanical complications of other specified prosthetic device, implant, and graft due to other implant and internal device, not elsewhere classified), should be used for the second procedure.

It is also possible that a gastroenterologist other than the one who performed the initial endoscopy will perform the repeat procedure. The original gastroenterologist might be doing a procedure on another patient or might not be on call if the patient returns during the evening. In this situation, the gastroentologist who performs the repeat procedure should attach modifier -77 (repeat procedure by another physician) to the endoscopy code, Pohlig says.

Use Modifier -25, Not Modifier -24, for E/M Services

If the patient appears to have complications, the gastroenterologist may also admit the patient to the observation room at the hospital or as an inpatient, depending on the seriousness of his or her condition. Chumley notes, however, that not all admissions to the hospital observation room are billable. An ERCP patient, for example, is usually admitted to the hospitals observation room for a couple of hours after the procedure to determine whether he or she will develop pancreatitis.

When a patient is admitted to the observation room of a hospital or as an inpatient, the admissions are reportable with either an observation or inpatient hospital care code (99218-99220 or 99234-99236) or an initial hospital care code (99221-99223). When these E/M services occur on the same calendar day as an endoscopy, Pohlig recommends attaching modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the postoperative E/M code. She cautions, however, that the gastroenterologist still needs to perform and document the work required of an E/M service, which includes a history, an examination of the patient and medical decision-making.

Lately, some gastroenterologists have been tempted to use modifier -24 (unrelated evaluation and management service by the same physician during a postoperative period) to avoid the reimbursement issues that have surrounded modifier -25. Modifier -24, however, was not meant for endoscopic procedures.

Modifier -24 was designed to be used with procedures that have global periods of 90 days to indicate that another totally unrelated procedure was being performed during that global period, Pohlig says.

Instead of looking for a different modifier, gastroenterologists can designate a different diagnosis code for the same-day, postoperative E/M encounter. Some local carriers are denying payment for same-day E/M services that didnt have different diagnosis codes, but HCFAs national office has instructed those carriers that there doesnt have to be a different diagnosis to get reimbursed, Pohlig says. To be safe, use a different diagnosis if you have it.

Commercial Payers May Not Reimburse

Medicare carriers will usually recognize the use of these modifiers to report postoperative care, but many commercial insurance companies may not reimburse for any postoperative care, even if it clearly falls outside of the global surgical package. Commercial insurers also will not generally pay for a postoperative E/M service on the same day as the procedure. You can always appeal, but dont be surprised if that is denied, says Pohlig, who also thinks it may be difficult to collect reimbursement for postoperative procedures as well.