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Wiki Modifiers for EGD & Colonoscopy

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Lassal423

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I have 2 procedure notes: one for a colonoscopy and one for an EGD done on the same date by the same physician. They are separate notes.
What are the thoughts around using a 51 or a 59 modifier in this situation?

Thanks for all the expertise!
 
Because the EGD and the Colonoscopy are two different anatomical part, I don't use the modifiers unless different techniques are used on separate sites of the same anatomical part. For example in a colonoscopy if a biopsy is done let say in the ascending colon and a snare polypectomy in the sigmoid colon then I would code as 45385 + 45380-59. But in your scenario I would code 432XX + 453XX with no modifiers. I have not had a problem getting it paid.

I hope this help!!
 
It usually depends on your carrier. Usually for our Medicare carrier, Anthem, and several commercial carriers we are not required to apply any modifier as these codes, while found in the surgery section, are considered diagnostic and carry no global days. Most carriers automatically do the 50% reduction on the claim. If you are more comfortable to use one of the two then use the 51 since FLIPS are done in the same session and the procedure code itself identifies the seperate sites.

Hope this helps.
 
I also agree with Nelenaz as no mod is needed as they are two different procedures. I do know with Medicare, special rules apply for multiple endoscopic procedures apply if the procedure is billed with another endoscopy in the same family, for example, another endoscopy that has the same base procedure. For example if you bill a 45382 with a 45385-59, both have a Multiple Surgery Indicator of 3, they share the same base CPT code of 45378, then the 45385 has the lowest fee schedule amount and the base code amount would be deducted from it.

Like this:

1/1/08 45382 fee schedule amount of 297.53
1/1/08 45385-59 fee schedule amount of 277.24

base scope, not billed, but these two codes share the same base procedure, is 194.76

this is how it will be reimbursed....

45382 will be paid at 100%,297.53
45385-59 will be paid at $82.48, 277.24-194.76=82.48


if they are not of the same family then only Mult Surgery Rules would apply with one paying 100%, the rest at 50%

I know this was way off of what kind of answer you were looking for, but thought it would be helpful in understanding at least the way medicare looks at the payment of procedures

hope this helps and hope I did not add confusion
 
:o ALL THE PAYORS PAY ON THE 2ND PROCEDURE EXCEPT FOR ANTHEM (THEY ONLY PAY FOR ONE PROCEDURE IN A DAY SO IT DOES NOT MATTER HOW MANY PROCEDURES YOU DO YOUR ONLY GETTING PAID FOR ONE). AND YOU DO NOT HAVE TO USE MODS TO DISTINGUISH BETWEEN AN UPPER AND A COLON. ONLY IF THERE ARE MULTIPLE CODES FOR COLON (I.E. 45380, 45385, 85384). HOPE THIS HELPS.
 
Colonscopy

I have another question in this area. Please advise how you might code this scenario.

Colonoscopy removal of polyps by snare/cautery and rectal polyps removed by biopsy forceps.

Also a colon polyp was removed in the transverse colon by snare/cautery.

This was done all at the same time.

Please help.

Thank you!
 
same question

I have a doctors office who coded a colonscopy with 45383, 45385 -59, 45384 -59 and an EGD 43239 - 59 and cant seem to get paid by BC/BS can any help me with this?:confused:
 
In regards to the modifier 59. We are an ASC and GHP has not been paying for our second procedure (i.e. 45385 and 45380-mod 59). they claim its a bundled code. Noticed on the Remittance Advice that they have been changing the modifier to a 51 (51 is not recognized in an ASC setting) So some claims are paid and some are not. It depends if GHP changed the modifier. I have a call out to our Rep. waiting for reply. Anyone else having these issues?????
 
mamacase1 said:
I have a doctors office who coded a colonscopy with 45383, 45385 -59, 45384 -59 and an EGD 43239 - 59 and cant seem to get paid by BC/BS can any help me with this?:confused:
Click to expand...

BC/BS only pays for one procedure in an ASC setting. You will have to write off the rest. But in a physicians office they pay on multiples.:mad:
 
Last edited:
We are always paid with use of mod-59 by Blue Cross. On occasion, Healthnet or Providence will deny the second code, but they are always overturned and paid on appeal. Definitely appeal these:)

Julie
 
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