Question Two EGD's done same day - denying due to bundling

jojokat

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Thomasville, GA
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We had a patient present to the ER with acute hematemesis and an urgent diagnostic EGD was performed in the ER at bedside at around 2:00a. gastric fundus was filled with old clots and blood, but no active bleeding sites were found at that time and 43235 was billed. Patient was transferred to ICU for close monitoring with recommendation for repeat EGD in 6-12 hours. Patient was taken to Endo suite at around 2:00p (14:00) where 2nd EGD was performed but this time control of bleeding was performed at site of shallow ulcers where adherent clot was documented in earlier EGD in the esophagus and 43255 was billed. According to NCCI edits there is not a modifier allowed to unbundle the procedures given the column 1/column 2 edits, but does anyone have any instances or thoughts on how to possibly go about showing that these were both separate services and medically necessary? We want try one more attempt at getting this paid if at all possible.

Any and all help would be appreciated. Thanks in advance.
 

lcolborn

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I just came across this, and if you haven't already solved this claim ..., I would append a modifier 76 on the second procedure indicating that a
procedure was repeated by the same physician( if not same physician use 77)and show that there was a controlled of bleeding/ medically necessary
that it does not represent a duplicated bill for the original surgery or service. I know you mentioned column 1 and 2 and without a modifier to unbundle, there
will be no payment on the latter. Most likely they will only pay the lowest RVU , unless you decided to cut the fist procedure in half by adding a 52.....
I wish you goodluck and keep us updated for future education on this case.
Thanks!
 

jojokat

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Thomasville, GA
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Thank you so much for your response Icolborn, we did try the 76 modifier. They paid on the EGD with control of bleeding (43255) but denied the 43235 as inclusive, even though the two procedures were 12 hours apart. There is apparently nothing we can do to get this paid in any way, but we tried our hardest.
 

prayercoder

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I'm thinking since the modifier indicator on those two codes is "0" and no modifier is allowed to override the edit, you may have to appeal. One would think you could use a 59 modifier to indicate a different session, or different procedure, but NCCI does not allow a modifier with these two codes. I would appeal and send operative notes for both procedures (make sure the date and time is on the notes) and a cover letter indicating why the two procedures were done.
 
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