Wiki Billing procedures

[mwells2020]

I billed 45338 (flexible sigmoidoscopy with removal of tumor(s), polyp(s) or other lesion(s) by snare technique and 43239 (EGD with biopsy) together with a 59 modifier on the EGD. The patient has United Healthcare insurance and they are denying the EGD. Can anyone help me to understand why?

 

[thranowski]

I am not very familiar with GI, but according to NCCI 2021 edits: "Only the more extensive endoscopic procedure may be reported for a patient encounter. For example, if a sigmoidoscopy is completed and the physician also performs a colonoscopy during the same patient encounter, only the colonoscopy may be reported."

Maybe you can try mod 51 to see if they will pay both? Not sure. Is there a way to just bill just the biopsy from the EGD separately?

Sorry, like I said I'm not too familiar with GI but just trying to help.

 

[mwells2020]

We have discussed trying the 51 modifier as well. Thank You so much for your help.

 

[dkissel]

Rarely, I have had to add modifier 59 on Colon/Sig with EGD but usually billing without any modifier results in full payment. Have you tried billing without any modifier?

 

[mwells2020]

No. I thought there had to be a modifier but we will try without one and see if we have any luck. Thank You so much for your help.

 

[thomas7331]

I billed 45338 (flexible sigmoidoscopy with removal of tumor(s), polyp(s) or other lesion(s) by snare technique and 43239 (EGD with biopsy) together with a 59 modifier on the EGD. The patient has United Healthcare insurance and they are denying the EGD. Can anyone help me to understand why?

What was their reason for the denial? These two procedures never require a modifier to unbundle because they always, by their own definitions, are at separate sites and require separate instruments. There must be a different reason for the denial. If they're saying it's bundled, then that's just an error on their part.