Tuesday, May 25, 2010

Multiple EGD 43245, 43248, 43239 and Modifier 59

43245 Esophagogastroduodenoscopy, flexible, transoral; with dilation of gastric/duodenal stricture(s) (eg, balloon, bougie)

43248 Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire $416.80

43249 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter) $608.39

Multiple EGDs? Pay Attention to Payer Guidelines and Code Order

Modifier 59 may not be part of every multi-EGD claim

To determine if your gastroenterologist merits more than one upper gastrointestinal endoscopy (EGD) CPT code for the same patient during the same encounter, you should look for biopsy details and such procedures as polyp removal and band ligation in the op notes.

When reporting multiple endoscopies from the 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate...) “family,” make sure you get the code order right. Then, you must know each of your payers’ reporting guidelines.

Bottom line: Although an upper gastrointestinal endoscopy takes a lot of time and expertise, multiple endoscopies require more of each. If you can’t report these encounters correctly, the claim may not secure your practice rightful payment for the encounter.

Know 43239: The Most Frequent Multi-EGD Code

When physicians perform multiple GI endoscopies, you’re most likely to see 43239 (... with biopsy, single or multiple) in combination with other codes from the 43245 family. In such a case, you should be sure to claim all reportable procedures to capture fully all the reimbursement your physician deserves.

“When an MD performs multiple EGD procedures in the same code set family [such as 43245 and 43239], you may submit both codes for payment,” says Susan Lariviere, CPC, MA, coder and auditor for RiverBend Medical Group in Agawam, Mass.

For example, if the gastroenterologist treats a patient for bleeding gastric ulcers, he may also take a biopsy in a separate upper GI area. When this occurs, you should: report the biopsy with 43239
use 43255 (... with control of bleeding, any method) to report the ulcer treatment attach modifier 59 (Distinct procedural service) to 43255 to show that the biopsy and ulcer care occurred at different sites.

Note: Although 43255 has a higher relative value unit (RVU) than 43239, when your gastroenterologist performs 43255 and 43239 together, you should put modifier 59 on 43255. This indicates that “the biopsy wasn’t the cause of the bleed,” Rumisek says.

Other multiple EGD scenarios you may see often include EGD with biopsy with: saline or Botox injection (43236, ... with directed submucosal injection[s], any substance) removal of tumor/polyp (43250, ... with removal of tumors[s], polyp[s], or other lesion[s] by hot biopsy forceps or bipolar cautery; 43251, ... with removal of tumor[s], polyp[s], or other lesion[s] by snare technique) band ligation of varices (43244, ... with band ligation of esophageal and/or gastric varices).

Code Combos Can Vary By Office

Other coders claim the most common EGD scenario is an esophageal dilation at the same time as a biopsy at a different site.

Scenario: A patient with dysphagia and reflux symptoms reports to the office. The gastroenterologist dilates the esophagus with a balloon catheter and biopsies a separate area where he suspects Barrett’s esophagus. On the claim, you should:

report 43249 (... with balloon dilation of esophagus [less than 30 mm diameter]) for the dilation
attach ICD-9 codes 787.2 (Dysphagia) and 530.81 (Esophageal reflux) to 43249 to prove medical necessity for the dilation report 43239 for the biopsy attach ICD-9 code 530.85 (Barrett’s esophagus) to 43239 to prove medical necessity for the biopsy attach modifier 59 to 43239 to show that the biopsy was separate from the dilation. Check Payers’ Modifier Requirements, Then File

Whether you should use modifiers on your multiple EGD claim will depend on the situation. You may be tempted to slap modifier 59 on each multiple EGD claim without even thinking about it. However, if you’re not sure that every payer wants modifier 59 on a multiple EGD claim, you cannot be sure that the claim will be clean.

Consider this example: The gastroenterologist performs an upper GI EGD with biopsy and a guidewire esophageal dilation in the same session. The CPT codes for this example are always the same.

On the claim, regardless of payer, you should report:

43248 (... with insertion of guidewire followed by dilation of esophagus over guidewire) for the dilation. 43239 for the biopsy.

The modifiers you attach on this claim will depend on your payer.

Why: Many coders would likely have to attach modifier 59 to 43239. But, for some commercial payers in some states, you may have to attach modifier 59 and modifier 51 (Multiple procedures) to get this combination paid.

Important: You should apply modifier 59 only when CMS or CPT normally bundle the procedures, but you need to indicate that the physician performed those procedures at separate (and thus non-bundled) locations. “I always verify with the Correct Coding Initiative (CCI) and other carriers before adding modifier 59,” Rumisek says.

Best advice: Don’t generalize. Take the time to learn each payer’s specific rules on reporting multiple EGDs. Some payers will want you to use a combo of modifiers; others might not want to see any modifiers at all. It’s up to you to know all payer guidelines before a multiple EGD claim hits your desk.


  1. interesting piece of information, I had come to know about your web-page from my friend pramod, jaipur,i have read atleast eight posts of yours by now, and let me tell you, your blog gives the best and the most interesting information. This is just the kind of information that i had been looking for, i'm already your rss reader now and i would regularly watch out for the new posts, once again hats off to you! Thanks a million once again, Regards Guidewire training in hyderabad

  2. I have a medicare patient who had a GI bleed. the Doctor spent 2 hours in the OR trying to control a bleeding ulcer. not sure how to get paid for time spent on a 43255. Help!


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