Forum - Questions & Answers

Aug 27th, 2022 - Mabel

EGD with biopsy and botox injection

Hello, Im a new GI coder. Have a patient that came in for EGD the provider took biopsies and injected botox due to dysphagia. What I came up with is 43239, 43236-59. Is this ok to bill together Egd guidelines are a little confusing to me. Thanks in advance.

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Sep 1st, 2022 - ChrisW   247  1 

re: EGD with biopsy and botox injection

I would verify with the payer to see the specific policies. This is not a simple answer; it will depend on the payer policy. CMS has specific rules, and other payers may differ. I have seen Modifier 59 and Modifier 51 used and sometimes both. The NCCI editor will tell you which procedure to append the modifier on. 
Take a look at the NCCI edits, and when you run your codes through the NCCI editor, you will see that *43236 is a Column 2 code – Indicating it can be used with a column 1 code. 

According to the NCCI Coding Policy Manual:  C. Endoscopic Services 2. If multiple endoscopic services are performed, the most comprehensive code describing the service(s) rendered shall be reported. If multiple services are performed and not adequately described by a single HCPCS/CPT code, more than one code may be reported. The multiple procedure modifier 51 should be appended to the secondary HCPCS/CPT code. Only medically necessary services may be reported. Incidental examination of other areas shall not be reported separately.
In addition, check out the Medicare Fee Schedule IndicatorsMultiple endoscopies are subject to the multiple endoscopy reduction rules and can be identified with an indicator of "3" in the multiple procedures. 1, 2, or 3, rank the procedures by fee schedule amount reduction to the code (100%, 50%, 50%, 50%, 50%, and by report).
CMS states this about Multiple endoscopies: 
Medicare has special payment rules for multiple endoscopies performed on same day. Modifier 51 will be added, by Noridian, to reduced services if necessary. Providers should not append this modifier on any services
Allowed amount reductions

See MPFS Indicator list for Endoscopy base codes
View Minor Surgery and Endoscopies for more about related/unrelated endoscopies and related/unrelated endoscopies on same day
IOM, Publication 100-04, Medicare Processing Manual, Chapter 12, Section 40.6C.13


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