Gastroenterology Coding Alert

Recognizing separate and multiple procedures is key

If you-re only reporting one code when your gastroenterologist performs two surgeries from the same endoscopic family on the same day, you may not be taking advantage of all the situations when you can use modifiers 59 and 51 -- which means you could be leaving money on the table.

For Close Codes, Use Modifier 59

Gastroenterology coders use modifier 59 (Distinct procedural service) to identify procedures that are distinctly separate from any other procedure or service the physician provides on the same date.
 
In general, you should append modifier 59 to procedure codes when the physician:
 
- sees a patient during a different session;
 
- treats a different site or organ system; or
 
- treats a separate injury.

In gastro offices, this modifier -is not usually used during office visits,- says Linda Parks, MA, CPC, CMC, CCP, coding consultant in Atlanta. -It's used when multiple procedures in the same endoscopic family are performed at the same time.-
 
Example 1: The gastroenterologist performs a colonoscopy with a cold biopsy and removes a separate polyp by snare technique.
 
You should:
 
- report 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s] or other lesion[s] by snare technique)
 
- attach modifier 59 to CPT 45380 (... with biopsy, single or multiple). The modifier shows the carrier that the physician treated two different sites.

-If these codes were billed without a modifier, 45380 could be bundled into 45385 [by the insurance carrier],- Parks says.
 
Example 2: The gastroenterologist performs an upper gastrointestinal endoscopy (EGD) with balloon dilation of the esophageal stricture and an EGD with biopsy of a gastric ulcer.
 
You should:
 
- report 43249 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with balloon dilation of esophagus [less than 30 mm diameter])
 
- attach modifier 59 to 43239 (... with biopsy, single or multiple). The modifier shows the carrier that the gastroenterologist performed two different procedures, even though they were both EGDs.

Remember: Code Order Matters

Make sure you know which code you are attaching modifier 59 to, or you could lose out on valuable reimbursement. -The modifier should always be placed on the code with the lower RVU [relative value unit], or the code that will be denied due to National Correct Coding Initiative edits,- Parks says.
 
Not sure about NCCI? If you-re stuck on whether you should bill codes with modifier 59, check the NCCI edits. If the codes you report have indicators of -1- next to them, you may be able to append an appropriate modifier to bypass the edit. If the code has a -0- indicator, you cannot bypass the edit. The NCCI edits change quarterly, so be sure to keep abreast of all updates.
 
Time saver: Increase your modifier 59 reimbursement rate by using it only when absolutely necessary -- many payers do not require the use of a modifier in multiple-procedure scenarios. Check with your individual payer to see if modifier 59 is necessary when reporting multiple-procedure claims.
 
On the other hand, don't be afraid to use modifier 59 if you have no recourse -- just make sure it is -the modifier of last resort.-

For Multiple Procedures, Use Modifier 51

When your physician treats a patient with multiple injuries requiring multiple procedures, you would include modifier 51 (Multiple procedures) on your claim.
 
Modifier 51 is -an informational-type modifier ... for use on the second, third, etc., surgical procedure performed on the same day,- says Barbara J. Girvin Riesser, RN, CCS, CCS-P, CPC, of Medical Management Resources in Kansas City, Mo.
 
For example, when a gastroenterologist extracts stones, he often uses removal and destruction methods in the same session.
 
When your gastroenterologist provides both removal and destruction procedures in the same session, you may be able to:
 
- report 43265 (Endoscopic retrograde cholangiopancreatography [ERCP]; with endoscopic retrograde destruction, lithotripsy of calculus/calculi, any method)
 
- append modifier 51 to 43264 (... with endoscopic retrograde removal of calculus/calculi from biliary and/or pancreatic ducts]). The modifier shows the carrier that the gastroenterologist performed removal and destruction procedures in the same session.

Check with your carrier first: Attaching modifier 51 to 43264 in the above example may not work with all insurance carriers. Many carriers, including Medicare, no longer require modifier 51. Processing claims electronically allows the carrier to recognize when your physician performs multiple procedures and automatically make the necessary reduction in payment.
 
Make a pre-emptive strike against denials by contacting your insurance carrier and asking the representative which method it would prefer when reporting multiple surgical procedures.
 
Then, make a note of each carrier's policy on coding multiple procedures so you can reference it quickly the next time a modifier 51 issue arises.
 
Remember: Although reimbursement rates for codes with modifier 59 attached vary by payer, expect half the normal reimbursement for codes with modifier 51 attached. (Most insurance companies have adopted Medicare's policy paying 50 percent for codes with modifier 51 attached.)