Gastroenterology Coding Alert

Question: Can I report biopsy ( CPT 45380 ) on the same days as removal (for instance, 45384, 45385)? My payer routinely rejects these claims. Should I append modifier 59?


Washington Subscriber


Answer: Many clinicians and coding experts would argue that you are justified in reporting foreign- body removal (43247, Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of foreign body). But--as you note--this would technically assume that the physician had removed the bolus from the patient's body entirely.

Clearly, however, the physician service in this case exceeds a simple diagnostic EGD (43235, -diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).

Therefore, to err on the side of caution, your best solution is to report 43247 and append modifier 52 (Reduced services). Include a brief note with your claim explaining that the physician dislodged the bolus into the stomach using the endoscope rather than removed it from the body entirely.

Your pay shouldn't suffer: Common sense would suggest that the physician isn't really doing less work by -dislodging- the bolus than he would by -removing- it. By appending 52, you are following the letter of the coding guidelines, but in this case you really shouldn't expect the insurer to reduce payment for 43247.