How to Adjust Procedure Coding to Abnormal Findings

Adjust Your Procedure Coding to Abnormal Findings

If the physician finds a lesion during a screening exam, you should no longer rely either G0105 or G0121 to describe the procedure. Instead, you would select the diagnostic colonoscopy (CPT Category I) code that properly identifies the resulting biopsy or removal.

For instance, if the physician discovers and biopsies a polyp during the exam for our 62-year-old, high risk patient described above, you would turn away from G0105 and instead report 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple).

Likewise, if the physician finds and removes by snare technique two colonic tumors during the exam of our 50-year-old patient, you would select 45383 (…with ablation of tumor[s], polyp[s] or other lesion[s] not amendable to removal by hot biopsy forceps, bipolar cautery or snare technique) over G0121.

How to Adjust Procedure Coding to Abnormal Findings

 Adjust Your Procedure Coding to Abnormal Findings

If the physician finds a lesion during a screening exam, you should no longer rely either G0105 or G0121 to describe the procedure. Instead, you would select the diagnostic colonoscopy (CPT Category I) code that properly identifies the resulting biopsy or removal.

For instance, if the physician discovers and biopsies a polyp during the exam for our 62-year-old, high risk patient described above, you would turn away from G0105 and instead report 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple).

Likewise, if the physician finds and removes by snare technique two colonic tumors during the exam of our 50-year-old patient, you would select 45383 (…with ablation of tumor[s], polyp[s] or other lesion[s] not amendable to removal by hot biopsy forceps, bipolar cautery or snare technique) over G0121.


Screening-Turned-Diagnostic Requires Second Diagnosis

5 Common GI/Endoscopy Coding and Billing Mistakes

 1. Control of bleeding not separately billable. The control of bleeding is included in biopsy (and most other) endoscopic procedures, and is not separately billable unless the patient comes into the facility with a GI bleed, which is the reason the procedure is being performed – which rarely occurs in the ASC setting.

Control of bleeding can be obtained through means of injections, as well as cauterizations. Injections of epinephrine through an upper endoscopy are coded as 43255. This injection would be included in the ASC facility fee and would not be reimbursed separately from an esophagogastroduodenoscopy or colonoscopy procedure unless the endoscopy case is completed and the patient is in the PACU/recovery area when the bleed occurs, necessitating a return to the OR to treat the hemorrhage.

The control of bleeding by colonoscopy is coded 45382. Append the -78 modifier to the CPT code for the return to the OR for control of bleeding procedures.

2. Only bill for successful surgery. If the physician performing a colonoscopy attempts — but fails — to remove a polyp by snare technique, but he/she is successful at removing the polyp via another technique (such as hot biopsy forceps), only bill the CPT code for the technique/procedure which was successful (use code 45374 for a hot biopsy forceps polypectomy in this case).

How to use Modifier 22 - do's and dont's

Five Pointers for More Effective GI Billing With Modifier -22

Modifier -22 Dos and Donts

There are no surefire solutions when it comes to getting reimbursed for codes appended with modifier -22. However, gastroenterologists might employ alternate strategies to get reimbursed for certain types of prolonged procedures. There are also situations when gastroenterologists shouldnt waste their time doing the extra paperwork it takes to file a claim that includes the modifier. Gastroenterologists should consider five points when faced with an unusual or prolonged procedure:

1. Dont use modifier -22 for multiple polyps. Save some time and dont use modifier -22 to report the removal of multiple polyps. Stout considers this an inappropriate use of the modifier. Even if the gastroenterologist takes two hours to remove 20 polyps, the CPT codes say polyp(s) and theres no way around that, she says.

More Effective GI Billing With Modifier -22

Five Pointers for More Effective GI Billing With Modifier -22

A colonoscopy is performed on a patient with a tortuous colon. Instead of taking the usual 20 minutes to complete, the gastroenterologist spends 90 minutes navigating the scope through the twists and turns of the patients lower intestine. Modifier -22 (unusual procedural services) is attached to the colonoscopy procedure code when the claim is filed, but the gastroenterologist feels a sense of frustration because he knows from experience that it is unlikely he will receive extra reimbursement despite his extra service. There is a way to ensure better pay up for these prolonged or unusual procedures.

Modifier -22 should be used when the service provided is above and beyond the scope of a normal procedure, says Pat Stout, CMC, CPC, an independent gastroenterology coding consultant and president of OneSource, a medical billing company in Knoxville, Tenn.

One reason for the lack of additional payment is that modifier -22 has been used inappropriately in the past. Modifier -22 has been so overutilized that many payers have quit acknowledging it, Stout says.

In recent years, Medicare has tried to crack down on what it believes is the inappropriate use of the modifier. In its January 1998 Medicare bulletin, Cigna Medicare, the Part B administrator for Tennessee, North Carolina and Idaho, complained that it sees much inappropriate use of modifier -22. Some physicians use it on almost all of their surgical procedures.


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