Gastroenterology Coding Alert

Question: The gastroenterologist treats a patient for bleeding gastric ulcers and also takes a biopsy in a separate upper GI area. How should I code for these procedures?

Louisiana Subscriber

Answer: In this case, you should report the biopsy with 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple). Use 43255 (... with control of bleeding, any method) to report the ulcer treatment. Attach modifier 59 (Distinct procedural service) to 43255 to show that the biopsy and ulcer care occurred at different sites.

When your gastroenterologist performs 43255 and 43239 together, you have to place modifier 59 on 43255 if your claim shows that the bleeding is separate from the biopsy and not caused by the biopsy. The reason is that the Correct Coding Initiative (CCI) bundles these codes since control of bleeding is considered part of every surgical procedure performed and can only be billed if it is a separate lesion/ulcer.

Watch out: There is often a misconception that the 59 modifier always goes on the less expensive procedure but it goes on the "component code" (column B in the CCI edits) which can occasionally be the most expensive procedure.