Practice Management Alert

Question: I work at a gastroenterologist’s office, and I’m having some modifier issues. According to encounter notes, a patient reported to our practice for a scheduled esophagogastroduodenoscopy (EGD) and colonoscopy. The gastroenterologist performed a flexible transoral EGD with catheter placement. Then, she performed a flexible diagnostic colonoscopy, and took two tissue samples for biopsy. I reported these codes with modifier 59, and got a denial. Why?

Connecticut Subscriber

Answer: You probably should have used modifier 51 (Multiple procedures) instead of modifier 59 (Distinct procedural services).

When you resubmit, be sure to report 43240 (Esophagogastroduodenoscopy, flexible, transoral; with transmural drainage of pseudocyst [includes placement of transmural drainage catheter[s]/stent[s], when performed, and endoscopic ultrasound, when performed]) for the EGD. Then, report 45380 (Colonoscopy, flexible; with biopsy, single or multiple) for the colonoscopy with modifier 51 appended to show that the physician performed two separate procedures.

Explanation: You should use modifier 51 in this instance because CPT^® bunches these codes in two different code “families”; in other words, the root codes for the procedures are different. The root code for 43240 is 43235 (Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]), and the root code for 45380 is 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]).

When the gastroenterologist performs two procedures that are in different code families, always choose modifier 51. Be sure to append modifier 51 to the lower-paying code, as the multiple-procedure payment rule is in effect.

On the other hand, you’d use modifier 59 (or one of the X modifiers: XE, XS, XP, XU) if the gastroenterologist performed two procedures that were in the same CPT^® code family.

For example, let’s say the gastroenterologist performed a colonoscopy with foreign body removal. During the colonoscopy, he detects and removes a separate polyp with hot biopsy forceps.

For this claim, you’d report 45384 (…with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps) for the polyp removal. Then, report 45379 (… with removal of foreign body[s]) with modifier 59 appended to show that the gastroenterologist performed two different procedures during the colonoscopy.

Explanation: The root code for both procedures is 45378.