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Modifiers for EGD & Colonoscopy

  1. #1
    Default Modifiers for EGD & Colonoscopy
    Medical Coding Books
    I have 2 procedure notes: one for a colonoscopy and one for an EGD done on the same date by the same physician. They are separate notes.
    What are the thoughts around using a 51 or a 59 modifier in this situation?

    Thanks for all the expertise!

  2. #2
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    Modifier -59 on the EGD (separate site)

  3. #3
    Default
    Because the EGD and the Colonoscopy are two different anatomical part, I don't use the modifiers unless different techniques are used on separate sites of the same anatomical part. For example in a colonoscopy if a biopsy is done let say in the ascending colon and a snare polypectomy in the sigmoid colon then I would code as 45385 + 45380-59. But in your scenario I would code 432XX + 453XX with no modifiers. I have not had a problem getting it paid.

    I hope this help!!
    NoRaX

  4. #4
    Default
    I dont use a modifier either when I code for EGD and colos. I have not had a problem yet with payment.
    Susie Corrado, CPC
    __________________
    ENT Coding/Billing

  5. #5
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    Those of you not using mod -59 on gastro or colon...are you being reimbursed the full contracted amount for both procedures?

  6. #6
    Default
    It usually depends on your carrier. Usually for our Medicare carrier, Anthem, and several commercial carriers we are not required to apply any modifier as these codes, while found in the surgery section, are considered diagnostic and carry no global days. Most carriers automatically do the 50% reduction on the claim. If you are more comfortable to use one of the two then use the 51 since FLIPS are done in the same session and the procedure code itself identifies the seperate sites.

    Hope this helps.
    Kimm Hall CPC, CMSCS, CGCS

    If you live to regret then you have not learned lifes lessons.

  7. Default
    I also agree with Nelenaz as no mod is needed as they are two different procedures. I do know with Medicare, special rules apply for multiple endoscopic procedures apply if the procedure is billed with another endoscopy in the same family, for example, another endoscopy that has the same base procedure. For example if you bill a 45382 with a 45385-59, both have a Multiple Surgery Indicator of 3, they share the same base CPT code of 45378, then the 45385 has the lowest fee schedule amount and the base code amount would be deducted from it.

    Like this:

    1/1/08 45382 fee schedule amount of 297.53
    1/1/08 45385-59 fee schedule amount of 277.24

    base scope, not billed, but these two codes share the same base procedure, is 194.76

    this is how it will be reimbursed....

    45382 will be paid at 100%,297.53
    45385-59 will be paid at $82.48, 277.24-194.76=82.48


    if they are not of the same family then only Mult Surgery Rules would apply with one paying 100%, the rest at 50%

    I know this was way off of what kind of answer you were looking for, but thought it would be helpful in understanding at least the way medicare looks at the payment of procedures

    hope this helps and hope I did not add confusion

  8. Talking
    ALL THE PAYORS PAY ON THE 2ND PROCEDURE EXCEPT FOR ANTHEM (THEY ONLY PAY FOR ONE PROCEDURE IN A DAY SO IT DOES NOT MATTER HOW MANY PROCEDURES YOU DO YOUR ONLY GETTING PAID FOR ONE). AND YOU DO NOT HAVE TO USE MODS TO DISTINGUISH BETWEEN AN UPPER AND A COLON. ONLY IF THERE ARE MULTIPLE CODES FOR COLON (I.E. 45380, 45385, 85384). HOPE THIS HELPS.

  9. Default Colonscopy
    I have another question in this area. Please advise how you might code this scenario.

    Colonoscopy removal of polyps by snare/cautery and rectal polyps removed by biopsy forceps.

    Also a colon polyp was removed in the transverse colon by snare/cautery.

    This was done all at the same time.

    Please help.

    Thank you!

  10. #10
    Location
    ENGLEWOOD/DENVER
    Posts
    2,338
    Default
    You may code each "technique" done in different areas of the colon
    45385 (for the snare)
    45380-59 (biopsy forceps)

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