Kelly Posted Wed 23rd of February, 2011 22:38:08 PM
What modifier should I use when our physician coded '45385' and '45382'? I agree with his use of the two codes after reading his report but should I use a 51 modifier on both or a 59 on just the second code? I am new to gastro coding so any help is much appreciated!
SuperCoder Answered Thu 24th of February, 2011 08:08:18 AM
As you have not provided the full report, you can read the usage of modifier and apply accordingly.
If the procedure is performed on the same day, the same operative session, on identical anatomical sites, then you could use modifier 50 (bilateral procedure [two sides])
When using a modifier 50, make sure you only bill for one unit on the claim form since there is only 1 procedure is performed bilaterally. Though guidelines from other payers may differ. They may require you to list it twice (line 1 and line 2 on the claim form). You have to be responsible to clarify this with your payors.
You use this modifier with add-on codes too! Do not use this modifier with procedures which are already described as bilateral procedures.
Modifier -59: Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day.
Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, 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.
Use this modifier only if the other procedure is a separately identifiable procedure code. Procedure that is distinct and can be described as independent procedure, on separate anatomical site, lesion, injury site, different organ system, and different session. Do not use this modifier for E/M code.
Carol Answered Fri 25th of February, 2011 15:50:17 PM
The two codes are of the same family of codes so do not use the modifier 51. Place the modifier 59 on the procedure you do NOT want to be reduced (use RVU's) and in this case, the 45382. You want to prove that the gastroenterologist did not cause a bleed after removing the polyp. If he used 45382 to control a bleed HE caused - you cannot use the code at all. It is difficult to assess since no description of what he did was provided. Hope this helps you
Catherine Answered Fri 01st of April, 2011 12:43:50 PM
Carol is correct. If the bleed was caused by the polypectomy, you cannot bill for it separately - it is part of the service. If physician stop a bleeder prior to polypectomy, and this procedure has nothing to do with the plyp that will be removed during the same service, you can bill for this with modifier 59 added to 45382.