Question: We have physicians that commonly do an EGD with biopsy (43239) and EGD with balloon dilation (43249)-or guidewire and dilation (43248).-We bill these out-as a 43248 or 43249 and 43239-51.-These items are not listed in the Correct Coding Initiative edits. However quite often carriers deny the 43239-51 as being bundled. Which is more appropriate for these two services, modifier 51 or modifier 59?
Answer:In most circumstances, you'll append modifier 59 (Distinct procedural service) to show that your gastroenterologist performed two related procedures (that you normally would not code together) on different sites. Modifier 51 (Multiple procedures) is typically for when your physician performs more than one unrelated procedure during the same encounter.
Bundling: These procedures fall in the same family of endoscopy codes, whose base is 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]). You can look for these code families on the National Physician Fee Schedule spreadsheet. Find the endoscopy code you want in column A, and then scan across to column AD, which is labeled "Endo Base." When you code any two procedures that share an "Endo Base" code, Medicare will bundle them. Download the fee schedule at www.cms.hhs.gov/PhysicianFeeSched.
Check with your payer: Some commercial payers in some states may want you to attach modifier 59 and modifier 51 to get this combination paid. Learn each payer's rules on reporting multiple EGDs.