Gastroenterology Coding Alert

Question: Whenever our gastroenterologist performs an EGD with balloon dilation and EGD with biopsy, we submit our claims using these codes 43249 and 43239-59. This is based on the RVUs: 43249 is 5.23 and 43239 is 5.15. However, we have now noticed that we are being paid with 43239 as the primary code although it carries lesser RVU. Can you explain?

Arkansas Subscriber

Answer: According to the coding scenario that you have provided, you are right in reporting the procedures with 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple) and 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]). You are correct until this point.

However, you should not report these codes with the modifier 59 (Distinct procedural service) because you will not find a National Correct Coding Initiative edit for this coding pair. Medicare does not consider these codes as bundled. Both codes are in the same family of codes so you also do not need to use the modifier 51 (Multiple procedures). The claims processing software will recognize these codes as being from the same family and should according to the usual rule. If the multiple endoscopies belong to the same group and are not bundled under NCCI, then the highest paying procedure is paid out at 100 percent. The other endoscopy(ies) will be paid out after deducting the value of the group's base code from the value paid out to the procedure performed.

Because some commercial carriers do bundle these codes you may want to append modifier 59 to the 43239 to show that the biopsy was separate from the dilation. Check with your carriers.

Note: 43235 should not be reported as a separate procedure if performed with other procedures such as a biopsy or the balloon dilation as this code is bundled into the procedural codes for these procedures.