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Ronda Posted Fri 08th of July, 2011 12:38:48 PM

Hi Everyone!

New to general surgery.....and I have a question. We do a lot of colonoscopy's and EDG's. They often do both procedures during the same session. For example, In the same surgical session the doc did a 45380 due to 569.3, 211.3 and 562.10 and a 43239 due to 535.10. I added a 59 modifier to 43239. I received a Medicare(WV) EOB today and they added the modifier 51 to the 43239 and only allowed 86.55. The allowed amount for a 43239 is 173.09. The reduced the allowed amount by $86.54. Is this right? This does not make since to me! But...again I'm new to general surgery.

The did they same thing to the codes below:

19125, 38525 and 38792 - They added a 51 to 38525 and 38792 and reduced the payment.

I just want to make sure I am not missing something! If I can get full reimbursements for both procedures, especially the 45380 and 43239, please let me know! They do that a lot!

Thank you so much!

West Virginia

Vicky Answered Fri 08th of July, 2011 15:58:23 PM

This is correct. First one pays at 100% and additional procedures on same date of service pay at $50% of allowable.

Carol Answered Tue 12th of July, 2011 14:51:20 PM

The payment is correct, however, because 43239 is of a different family - you need to put the modifier 51, not 59. You can use the modifier 59 if, during the colonoscopy with polypectomy (45385) doctor also did a biopsy from a different site, you can add the 59 to the 45380 for an additional payment. Medicare does pay for different techniques used during the colonoscopy session but be sure to add the modifier 59.

SuperCoder Answered Tue 12th of July, 2011 15:50:44 PM

Agree with Carol 100%.

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