Wiki 99223 with endoscopy same day

[hhornsby]

Hello everyone. New to GI billing and we have billed Medicare for 99223 with 57 modifier with a 43235. Patient was examined and it was determined by exam to do the procedure. Medicare is denying 99223 as it is included in procedure. IS there a different way I should be billing this?

 

[thomas7331]

Modifier 57 is for the decision to perform a major surgery (i.e. a surgery with a 90-day global period). 43235 is a minor surgery so that modifier would not be correct here.

Because the decision for a minor surgery is consider included in the surgical package, that decision, by itself, does not warrant billing a separate E/M service. But if the documentation supports that there is sufficient work in the evaluation that is above and beyond the decision to perform the endoscopy, then it may be appropriate to bill the E/M with the modifier 25 instead.