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Field Guide to Physician Coding 3rd Edition


Forum Discussion Areas > Ask Us a Question > Appropriate Coding for 45380 and 45385
  Appropriate Coding for 45380 and 45385
Appropriate Coding for 45380 and 45385
Nov 4 2009, 5:43 PM
The Physician that I work for performed two separate procedures on different polyps during a colonoscopy. I coded both procedures with a 59 Modifier and it was rejected by Medicare, which stated that "The payment is included in the allowance for another service/procedure." What valid information can I use to appeal this claim for reconsideration?

Codapedia Editor
Appropriate coding for 45380 and 45385
Nov 5 2009, 4:17 PM
The NCCI edits show that 45380 is a component code of 45385 but may be billed with a modifier. You say that these were two separate lesions, so that meets the criteria.

Bill the code with the highest RVU first, with NO modifier: 45385 Then, the second is billed with the 59 modifier.

There's an article about colonoscopy in Codapedia.

Send a copy of the NCCI edits. Never put the 59 modifier on the first code.

CCI Edits
Nov 9 2009, 3:41 PM
I wanted to mention that, although the 59 modifier usually goes on the lower RVU code, this isn't always true. Case in point: 45382 (colonoscopy with control of bleeding, any method) billed with 45384 (colonoscopy with hot biopsy forceps/cautery) is billed as 45382-59, 45384. CPT 45382 has 8.87 facility RVUs and 45384 has 7.22. The modifier goes on the code in column 2 of the CCI edits tables. It all depends on the CCI edits and how they are grouped.

See this FAQ from CMS: How should modifier -59 be reported under the CCI? Feedback How should modifier -59 be reported under the CCI? Answer Modifier -59 is used to indicate a distinct procedural service. To appropriately report this modifier, append modifier -59 to the column 2 code to indicate that the procedure or service was independent from other services performed on the same day. The addition of this modifier indicates to the carriers or fiscal intermediaries that the procedure or service represents a distinct procedure or service from others billed on the same date of service. In other words, this may represent a different session, different anatomical site or organ system, separate incision/excision, different lesion, or different injury or area of injury (in extensive injuries). When used with a CCI edit, modifier -59 indicates that the procedures are different surgeries when performed at different operative areas or at different patient encounters. (1/10/03)

Jenny Berkshire, CPC, CGIC, CEMC


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