Modifier Coding Alert

Reader Question:

Check Coding 'Family' Before Deciding on 59 or 51

Published on Fri Dec 18, 2015

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Question: A patient reported to our practice for a scheduled esophagogastroduodenoscopy (EGD) and colonoscopy. The gastroenterologist performed a flexible transoral EGD with catheter placement. Then, she performed a flexible diagnostic colonoscopy, and took two tissue samples for biopsy. I reported these codes with modifier 59, and got a denial. Why?

California Subscriber

Answer: Provided your coding was correct, you likely chose the wrong modifier for the claim.

When you resubmit, be sure to report 43240 (Esophagogastroduodenoscopy, flexible, transoral; with transmural drainage of pseudocyst [includes placement of transmural drainage catheter[s]/ stent[s], when performed, and endoscopic ultrasound, when performed]) for the EGD. Then, report 45380 (Colonoscopy, flexible; with biopsy, single or multiple) for the colonoscopy with modifier 51 (Multiple procedures) appended to show that the physician performed two separate procedures.

Explanation: You should not use modifier 59 (Distinct procedural service) in this instance because CPT® bunches these codes in two different families; when the gastroenterologist performs two procedures that are in different code families, always choose modifier 51. Be sure to append modifier 51 to the lower-paying code, as the multiple-procedure payment rule is in effect. On the other hand, you’d use modifier 59 (or one of the X modifiers: XE, XS, XP, XU) if the gastroenterologist performed two procedures that were in different CPT® families.

For example, let’s say the gastroenterologist performed a colonoscopy with foreign body removal. During the colonoscopy, he detects and removes a separate polyp with hot biopsy forceps.

For this claim, you’d report 45384 (…with removal of tumor[s], polyp[s], or other lesion[s] by hot biopsy forceps) for the polyp removal. Then, report 45379 (… with removal of foreign body[s]) with modifier 59 appended to show that the gastroenterologist performed two different procedures during the colonoscopy.