Gastroenterology Coding Alert

Overuse of modifier -59 (Distinct procedural service) raises red flags and invites audits, but knowing some typical gastroenterology scenarios in which to use it will steer you to the path of reimbursement success. Biopsy, Polypectomy Are on Different Sites When a gastroenterologist biopsies and removes the same polyp, the Correct Coding Initiative bundles the procedures, says Staci Jordan, CPC, CCS-P, reimbursement analyst for the University of Oklahoma Health Sciences Center in Oklahoma City. However, if a polyp is biopsied and a separate lesion is removed, you may report both procedures.

For instance, a gastroenterologist removes one polyp using hot biopsy forceps and biopsies a separate lesion using cold forceps. Assign 45384 and CPT 45380 -59-51, Jordan says. For the hot biopsy removal, report 45384 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery). For the biopsy, use 45380 ( with biopsy, single or multiple).

"Append modifier -59 to the lower relative value unit (RVU) procedure, no matter what was done second," says Barbara Cobuzzi, MBA, CPC, CPC-H, president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. The removal (45384) is a higher-valued procedure (7.07 facility RVUs) than the biopsy (45380, 6.7 facility RVUs). So, append modifier -59 to 45380 to indicate the removal occurred at a separate site from the biopsy.

"You need to let the insurance know that you are not trying to bill for the biopsy of the same polyp twice," Jordan says. "Modifier -59 on 45380 tells the payer that two separate distinct, procedures were performed one polyp was removed using hot biopsy forceps, and a separate lesion/polyp was biopsied using cold forceps. However, if you biopsied the polyp using cold forceps and then subsequently removed that same polyp using hot biopsy forceps, you can only charge for the hot biopsy."

In addition, Jordan adds modifier -51 (Multiple procedures) to the biopsy code to indicate multiple procedures. Although coding experts and the American College of Gastroenterologists advocate this method, the CCI does not require the multiple-procedures designation.

The CCI bundles biopsy codes (43202, 43239, 44361, 45331, 45380) with removal by hot forceps (43216, 43250, 44365, 45333, 45384) and the removal by snare technique codes (43217, 43251, 44364, 45338, 45385). These edits contain a superscript of 1, meaning that under certain situations modifier -59 is appropriate to break the bundle. The modifier by definition makes both procedures separate, not incidental. Since no clear rules exist, contact your individual carriers for their policies. Other Modifier Is More Appropriate "Modifier -59 is the modifier of last resort," Jordan says. "When another already-established modifier is appropriate it should be used rather that modifier -59," states CPT. "Only if [...]