Gastroenterology Coding Alert

Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.
Question: How should I code when the physician performs a colonoscopy and an EGD on an outpatient on the same day? Should I bill them together or in two separate billings? Alabama Subscriber

Answer: Coding for multiple endoscopies seems to cause problems for many gastroenterology coders, but it need not be so difficult. There are two things you need to remember: Medicare's multiple-endoscopy rule and the Correct Coding Initiative (CCI) edits. EGDs and colonoscopies have different base codes, meaning they are unrelated in Medicare lingo. For example, say the doctor performs 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) and 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]). According to Medicare guidelines, these two endoscopies are unrelated and should be listed in descending order without any modifiers.

Next, you need to look at the CCI edits. You will see that these codes are not bundled; therefore, modifier -59 (Distinct procedural service) is not required.

This is the point where things get confusing, because "correct coding" is often different from coding that is accepted by carriers. For example, although Medicare states that no modifier is needed in this instance, many coders still append modifier -59 for these unrelated procedures. Modifier -59 will simply show that these are two separate and distinct procedural services. Whichever method you choose, with or without modifier -59, you should be reimbursed 100 percent of the highest-valued procedure (45378) and 50 percent of the EGD.