Gastroenterology Coding Alert

Question: Our pediatric gastroenterologist scheduled a patient for an EGD with biopsy, coordinating with one of our adult GI docs to do an EUS during the same session. My claims will have the same group tax ID, but different NPIs. Can I bill it with 43242? Should I submit the 43239 with modifier 59? What about 43242? They were not totally separate procedures.

Virginia Subscriber

Answer: No, you cannot bill it with 43242 (Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s)…). Nor can you use modifier 62 (Two surgeons) as 43242 describes an EUS with FNA (fine needle aspiration). That would be used for an ultrasound guided needle aspiration or biopsy. As per your description, it seems the biopsy done here was not ultrasound guided, and each physician used a separate scope.

Therefore, the correct reporting in this scenario would be 43259 (Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination, including the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis) and then 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple) with modifier 59 (Distinct procedural service). You cannot use Modifier 62 because you have described different procedures, and the GI docs are working sequentially rather than concurrently. 

The Correct Coding Initiative (CCI) bundles 43239 into 43259 unless a modifier is appended, so you will need to append modifier 59 to 43239 if they want both codes paid, given the common tax ID number (i.e., both physicians billing under the same group number). Make certain, however, you have documentation to support this. Nothing in CPT® precludes reporting both codes together (at least there is no parenthetical to that effect). 

Note: Some coders may think that modifier 51 (Multiple procedures) might also need to be appended to 43239, but that is not the case, since both of these codes are modifier 51 exempt, per CPT®