Gastroenterology Coding Alert

You Be the Coder:

Modifier 22 Comes to the Rescue in Complicated Excision Procedures

Published on Tue Mar 03, 2015

Question: Our GI was performing a polyp excision recently and he documented the polyp head as firm and ulcerated and oozing on several sites. The physician tried to dislodge the polyp into stomach using multiple attempts and accessories. He used forceps, several snares, biliary stone retrieval balloon inflated to 20 mm, and a standard esophageal dilation balloon inflated to 20 cm but failed to move the huge polyp through the pylorus into duodenum. He even tried using a double channel scope and two CRE balloons but even that did not budge the polyp. How should I code this procedure?

New York Subscriber

Answer: Based on this description, we believe a large polyp was removed in the stomach, and rather than retrieve it, the physician tried to push it through the pylorus. Although the polyp was not retrieved, your description suggests that a significant effort was needed in an attempt to push the polyp into the duodenum where it could pass spontaneously through the GI tract.

If that is the case, then you should report code 43251 (Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique). You should then attach modifier22 (Increased procedural services) to the claim, as the service(s) the physician provided is substantially greater than typically required.

The primary purpose of the modifier is to denote circumstances for which a procedure or service required an “unusual” amount of time or effort to perform. This modifier indicates that a procedure was complicated, complex, difficult, or took significantly more time than usually required by the provider to complete the procedure.

Its use implies that the procedure or service was distinctly more time-consuming or difficult to perform, more complicated or took significantly more time than usual to complete.

Ensure that a special report is attached by the GI in the billing that describes the unusual nature of the service and justifies the additional charge.

Caution: Modifier 22 should be used to report only procedures that have a 0, 10, or 90 day global period that required a level of work far more extensive than usually necessary for the listed procedure.

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