Gastroenterology Coding Alert

Answer: Because these two procedures have the same endoscopic base code 43235 (upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) but are not bundled together under the Correct Coding Initiative (CCI), they will fall under the multiple endoscopy payment rule. The full value of the highest-valued procedure will be paid, plus the difference between the value of the remaining procedure and the base endoscopic procedure, according to section 15038.B of the Medicare Carriers Manual. This payment rule probably also will apply to most commercial insurance companies.

Modifier -51 (multiple procedures) should be attached to the lesser-valued procedure. When billing for multiple surgeries on the same day, gastroenterologists should report the more major surgical procedure without the multiple procedures modifier -51, section 4826.B of the Medicare Carriers Manual states. Report additional surgical procedures performed by the surgeon on the same day with modifier -51.

Some local Medicare carriers and commercial insurance companies will say that it doesnt matter whether you add the modifier -51 because their computer systems are set up to process the claim correctly in either situation. You may want to consult with your local payer before submitting this claim to get its specific coding instructions.