Gastroenterology Coding Alert

Know when and when not to append modifier 59.

GI procedure codes are notorious for being very specific. This can lead to confusion because while sometimes you’re supposed to submit one code when multiple procedures are performed during a single session, other times, multiple procedure codes are required for reimbursement. Even then, sometimes modifier 59 (Distinct procedural service) is required, sometimes not.

If you’re seeing denials related to this issue more often than you’d like, we’re here to help. Here are a handful of tips to help you figure it all out.

Tip 1: Look for “(Separate Procedure)”

When descriptors include several details, hastily choosing a procedure code can turn out being costly.

The first thing to watch out for is when a descriptor says “(separate procedure).” For example, you see this descriptor verbiage with CPT^® code 43235 (Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)).

Typically, this means you can report it as a standalone procedure. However, if the physician performs it in conjunction with a more major procedure, it’s generally considered an integral part of that major procedure and is not separately reportable. “For GI endoscopy, these ‘separate procedure’ designations are the ‘base code’ of a family of codes, and anything within the family when reported includes the work of the base code, so is not separately reported,” says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel advisor for ASGE in Pasadena, California.

Tip 2: Make Sure the Descriptors Match the Procedure(s)

Not all procedure codes include that separate procedure information. Let’s say the gastroenterologist performed an EGD on a patient with achalasia. The notes say that the physician performed a diagnostic EGD, inserted a balloon with the fluoroscope to visualize inflation, and achieved dilation with a balloon greater than 30 mm. It is also

clear from the notes that there is a risk for esophageal perforation during dilation, which is the reason for the fluoroscopy — to guide the procedure and keep it safer.

Using this information, take a look at the following esophagogastroduodenoscopy (EGD) and esophagoscopies codes that include dilation:

• 43220 (Esophagoscopy, flexible, transoral; with transendoscopic balloon dilation (less than 30 mm diameter))
• 43214 (Esophagoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed)).
• 43233 (Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed))
• 43249 (Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter))

Guided dilation: One detail to pay attention to is the dilation with fluoroscope guidance. Even though dilation codes exist, you should not report code 74360 (Intraluminal dilation of strictures and/or obstructions (eg, esophagus), radiological supervision and interpretation) for the fluoroscopy as it is included in the procedure description for code 43233.

Unguided dilation: When your gastroenterologist uses a dilator without the aid of endoscopy or a guide wire, or performs a diagnostic endoscopy prior to the use of a dilator, you’ll report the procedure using 43450 (Dilation of esophagus, by unguided sound or bougie, single or multiple passes).

Coding alert: If your gastroenterologist performed an endoscopy prior to the procedure, then you need to report it separately using 43235 or 43200 (Esophagoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)) depending on the extent of the visualization.

Tip 3: Remember to Check NCCI Edits

Sometimes it takes more than just carefully reading descriptors to be able to determine which procedural components to report separately. Be sure to check National Correct Coding Initiative (NCCI) edits to check whether certain procedures are bundled.

To use dilation as an example again, according to NCCI edits, you cannot report dilation codes such as 43248 or 43249 when your clinician performs the following procedures in the same session:

• 43212 (Esophagoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed))
• 43229 (…with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed))

Tip 4: Don’t Overdo Modifier 59

Modifier 59 is one of the most common modifiers used to bypass NCCI edits, indicating that two codes usually bundled together are appropriate to bill separately

under the circumstances outlined in the documentation. When you look up the codes in question, you’ll see whether appending the modifier will or will not allow you to override the rule.

For example, NCCI bundles 45380 (Colonoscopy, flexible; with biopsy, single or multiple) into 45385 (Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique). Under certain circumstances, you can report them together with the modifier. Let’s say the physician biopsies one lesion and removes a separate polyp. Report the biopsy with 45380 and the removal of the separate lesion with 45385. You’ll need to 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.

Note: Typically, you should append the 59 modifier to the lower-valued procedure to indicate to the payer that it is distinct and separate from the higher-valued procedure that was performed during the same session. This helps support medical necessity while also ensuring the provider is adequately reimbursed.

Coding alert: 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 the claim.

Don’t forget: As we reported in detail in Gastroenterology Coding Alert Volume 25, Number 7, performing two procedures does not automatically mean you’ll need to append the 59 modifier. Commonly, coders think they’re avoiding a hassle by appending modifier 59 for all separate procedures, regardless of whether they’re even bundled. These claims almost always get denied, which creates more of a hassle than what the coder was trying to dodge in the first place. Rather than considering it a default code, “only use this modifier if it [modifier 59] best describes the circumstances,” said Arlene Dunphy, provider outreach and education consultant at the Medicare Administrative Contractor (MAC) National Government Services (NGS) in her webinar, “The National Correct Coding Initiative and Medically Unlikely Edits.”