Gastroenterology Coding Alert

You Be the Coder:

Clear Confusion Over Reporting Different EGD Procedures by Different Clinicians

Published on Fri May 23, 2014

Question: Our pediatric gastroenterologist scheduled a patient for an EGD, coordinating with one of our adult GI’s doc’s to do an EUS during the same session. The pediatric GI does an EGD with biopsy (43239). Our other GI doctor does the EUS to look specifically at the ampulla and biliary system, after the first doctor is finished (43259). So we have two doctors during the same session performing different procedures. When I look at modifier -62, sounds like the same CPT® codes are reported. I researched CMS and they say no modifier is needed if the CPT® codes are different. (Which sounds odd to me, because it’s the same session - why would everyone get paid full amounts?) My concern is that 43239 is bundled into 43259. My claims will have the same group tax ID, but different NPI’s. So, should I submit the 43239 with modifier -59?

Illinois Subscriber

Answer: In this scenario that you have described, the correct codes that you would be reporting are 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 (...with biopsy, single or multiple). Append the modifier 59(Distinct procedural service)to 43239 as they are distinct procedures performed by two different clinicians.

As you have surmised, modifier 62 (Two Surgeons) is not applicable here because different procedures are involved and the GI docs are working sequentially rather than concurrently. You can only use this modifier if both the doctors are performing the same procedure and you are reporting the same CPT® code for both the doctors.

Correct Coding Initiative (CCI) edits bundle 43239 into 43259 unless a modifier is appended, so modifier 59 will need to be appended to 43239 if they want both codes paid, given the common tax ID number (i.e. both physicians billing under the same group number). Nothing in CPT® precludes reporting both codes together (at least there is no parenthetical to that effect).

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