Inpatient Facility Coding & Compliance Alert

Question: Our gastroenterologist just attended to a Medicare inpatient and performed an EGD with biopsy and control of bleeding. The E/M was of highest level. How should I code this encounter? Medicare denied control of bleed (43255) as the procedure under correct coding initiative (CCI) guidelines. Does Medicare cover/process codes in the order they are listed on the claim?

Missouri Subscriber

Answer: As the physician attended to an inpatient, the E/M code will come from the Initial Hospital Care 99221-99223 code range. According to your description, the appropriate code would be:

99223 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components:

• A comprehensive history;

• A comprehensive examination; and

• Medical decision making of high complexity).
  

You need to attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code to show that the E/M was a separately identifiable service from the EGD.

You can report the esophagogastroduodenoscopy (EGD) w/ biopsy with CPT® code 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple). EGD with control of bleeding is reported with 43255 (Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method). You may have gotten the denial for control of bleeding because you did not attach modifier 59 (Distinct procedural service) to 43255.

Keep in mind that when bleeding occurs as a result of an endoscopic procedure, control of bleeding is not reported separately during the same operative session and Medicare will not pay for it. So, if your physician caused the bleeding when completing the biopsy, the bleeding is not separately reportable. Medicare will normally switch the order of the codes according to RVUs when processing the claim, but this will not affect whether they deny or make payment on a claim.

If control of bleeding was the primary reason for the EGD, for example, a bleeding gastric ulcer (531.01, Acute gastric ulcer with hemorrhage with obstruction), make sure to attach detailed physician notes and his reasons for justifying the conclusion.