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Colon/EGD Modifier

  1. Default Colon/EGD Modifier
    Medical Coding Books
    I'm having trouble with Modifiers 51 and 59. Doctor did and colonoscopy 45378 and EGD 43235 during the same session. I've used the 59 modifier on the EGD to show separate procedure. An insurance company indicated the modifier should have been 51. Please help. Thanks

  2. Default
    Modifier 59 (Distinct Procedural Service) is only used when no other modifier better describes the situation. According to Appendix A in the CPT book on page 530 "...when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used."

  3. #3
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    Greeley, Colorado
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    Quote Originally Posted by 01115176 View Post
    I'm having trouble with Modifiers 51 and 59. Doctor did and colonoscopy 45378 and EGD 43235 during the same session. I've used the 59 modifier on the EGD to show separate procedure. An insurance company indicated the modifier should have been 51. Please help. Thanks
    Modifier -59 is the correct modifier in this case. You shouldn't need one at all, but often payors want one. I'd appeal. Argue that the procedures are technically different sites (one enters through the mouth, one enters through the rectum)...sometimes they need that pointed out to them.
    Lisa Bledsoe, CPC, CPMA

  4. #4
    Smile Mod 59 vs 51
    Modifier 59 is really not needed in this case. Check your CCI edits and you'll not find 45378 and 43235 paired in any way so a modifier is not required. I bill these two procedures together without and get paid just fine. Medicare automatically adds a mod 51 but you may need to append it with other insurances to show you performed more than one procedure at that same session by the same provider.

  5. #5
    Location
    Columbia, MO
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    You do not need modifier 59 because this modifier is used when you need to make a procedure distinc and separate from the other procedure performed in the same session, in other words to keep it from being considered bundled together. You do not need to make this distinction for this pair as it is inherent in their description that they are two disctinct and separate procedures...... you cannot ever examine the esophagus via a colonoscopic approach. Therefor there is not ever going to be an issure of bumndleing. The 51 modifier is correct as it indicates that both procedures were performed in the same session

    Debra A. Mitchell, MSPH, CPC-H

  6. #6
    Location
    Charlotte, NC
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    I agree with the lot of you, you don't need the 59 here, but I've seen a payor using their own edits. UHC is not paying for a colon/egd, unless you use a 59 mod, at least with the practice I'm at. My Supe went online and found out they do use the McKesson edits but can also add their own if they want to and it looks like they have.

  7. #7
    Location
    Greeley, Colorado
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    Like I said, you shouldn't need one but many payors want one or they won't pay for both.
    Lisa Bledsoe, CPC, CPMA

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