Gastroenterology Coding Alert

Biopsies:

Answer These 3 Biopsy FAQs to Submit Clean Claims Every Time

Published on Thu Mar 17, 2022

Hint: Watching the NCCI edits will be critical when evaluating these scenarios.

When your gastroenterologist performs procedures like colonoscopies and upper GIs, chances are strong that they might also biopsy the patient. This may occur to investigate issues such as whether any lesions or polyps are cancerous, or if the lining has some specific inflammatory disease.

In these situations, it will be up to you to determine which codes apply, and sometimes these scenarios will be tricky. Test yourself with three quick scenarios to determine whether you know how to bill biopsies properly.

Below you’ll find questions that subscribers have submitted to Gastroenterology Coding Alert, along with the answers that will help you code these situations properly every time.

1. Can You Report Biopsy and Removal Together?

Question: If you append modifier 59 (Distinct procedural service), can you report a biopsy (45380, Colonoscopy, flexible; with biopsy, single or multiple) on the same days as tumor removal (for instance, 45384, Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps)?

Answer: The National Correct Coding Initiative bundles 45380 into 45384. Under certain circumstances, you can report them together with the modifier, but that is not a typical occurrence. For instance, if the biopsy and removal take place during separate sessions, or if the gastroenterologist biopsies something separate than the removed polyp, you may be able to use modifier 59 to override the edit. “The most common example is when there are two different lesions in different parts of the colon which require different techniques to deal with, such as snare removal of one polyp and biopsy of a different lesion (a cancer, or colitis),” says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^®Editorial Panel member in Pasadena, California.

For example: The physician biopsies one lesion and removes a separate polyp. Report the biopsy with 45380 and the removal of the separate lesion with 45384. Because the removal code is the higher-valued procedure, you should append modifier 59 to the biopsy (45380) and include documentation that clearly states that the biopsy and removal(s) occurred at different sites for different lesions.

If the gastroenterologist biopsies and removes the same lesion, the procedures would not qualify as distinct procedural services. In such a case, you should code the removal only, and leave the biopsy code off of the claim.

2. Discover How to Code Separate-Site Biopsies

Question: The documentation states that the gastroenterologist performed an esophagogastroduodenoscopy (EGD) and placed three hemoclips to control bleeding. He also took a biopsy from the antrum portion of the stomach, as well as from the GE junction near the esophagus for H. pylori. Which codes apply to this situation?

Answer: You may report codes 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple) for the biopsy and 43255 (Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method) for control of bleeding, as long as the bleeding was not a result of the biopsy. If the surgeon caused the bleeding during the procedure itself, you should only report 43239. If the surgeon did not cause the bleeding, both codes can be reported by adding modifier 59 to 43255.

The EGD codes should be selected based on method and not sites, which means that even if the physician biopsied several sites, you can only report 43239 once if they were performed using the same method. You can also tell from the descriptor that this one code covers multiple sites, due to inclusion of the verbiage, “single or multiple.”

The only outlier would be if the physician used multiple methods for biopsy. For instance, if a second biopsy was performed using the snare technique, you could report 43251 (Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique) for that service, with modifier 59 appended.

3. Differentiate Balloon/Bougie Codes

Question: The physician performs an esophageoduodenoscopy with biopsies and also documents “esophageal dilation with balloon/bougie.” How should you report these services?

Answer: The correct code for reporting the EGD with biopsies would be 43239. For reporting EGD with esophageal dilation by using balloon/bougie, you have a choice of codes.

For balloon dilation, you can either report code 43249 (Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter)) or 43233 (Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed)) depending on the size of dilation. “The code 43233 reports a fairly rare procedure done to treat achalasia by disrupting the muscle fibers of the lower esophageal sphincter to relieve trouble swallowing,” Littenberg says. “The typical esophageal stricture uses smaller balloons of less than 30mm.”

For bougie dilation, you can use 43450 (Dilation of esophagus, by unguided sound or bougie, single or multiple passes). Keep in mind, however, that the NCCI lists 43450 as a column two code for 43249 and 43233. Therefore, you can only report either bougie or balloon dilation — not both. Check the documentation carefully to determine which procedure the physician performed, and bill your services accordingly based on the records.