Gastroenterology Coding Alert

When a patient is having several endoscopic procedures on the same day, the gastroenterologist must determine how to charge. For example, how would you code a colonoscopy done with polypectomy, and a biopsy done in a different site from the polyp removal? We talked to four practices for answers.

1. Do not use modifier -51. This is one of the biggest mistakes made by gastroenterology coders, because if you use it, it will reduce your fees unnecessarily, explains Susan Callaway-Stradley, CPC, senior consultant for the Medical Group, Elliott, Davis & Co. in Augusta, GA. If youre doing two endoscopies from the same family, you would never use a -51 modifier, she says. That would mean you would get an extra 50 percent taken off. Lets say youre doing a dilation (43249) and a biopsy (43239). These are both in the same family, both being done under endoscopy. Medicare pays for them in this way: full price for the first procedure, and the second procedure would be paid by subtracting the cost of the base procedure. In this case, the base procedure is the upper gastrointestinal endoscopy (43235). In Callaway-Stradleys state, Medicare pays $191 for 43249 (which you would call the first procedure), $178 for the 43239 (the second procedure), and $158 for 43235 (the base procedure). The payment for 43249 and 43239, therefore, would be $191, plus $20 ($178 minus $158), or $211. Theyre not going to pay you twice to put the scope down, so that is the rationale behind the subtraction. "If you add modifier -51, Medicare will gladly reduce the $20 to $10," says Callaway-Stradley. Many practices lose money by this inappropriate use of modifier -51.

2. The modifier -59 route...may be necessary. While modifier -59 is the modifier of last resort, to be used only when other modifiers are not appropriate, it may be needed to get reimbursed for the biopsy, says Jean Mead, billing manager for Gastroenterology Associates, a five-gastroenterologist practice in Mineola, NY. Modifier -59 is for a distinct procedural service, and the biopsy, says Mead, would qualify if it were done in a different site from the other procedure (see definition in box on this page). Recently, Medicare has stopped paying for a biopsy done at a different site during a colonoscopy with a polypectomy, she says. So now the practice is using modifier -59 on the biopsy ( CPT 45380 ). We get back half of the biopsy fee, says Mead. As for commercial payers, it is much more difficult to get paid for the biopsy, no matter what modifier you use, she adds. But sometimes it does help to send an operative note.

Modifier -59: Distinct Procedural Service
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