Gastroenterology Coding: 43255 And Control-Of-Bleeding Situations

Gastroenterology coding: 43255 and control-of-bleeding situations

Coding for excessive blood loss? If so, modifier 22 may not be the ally you are looking for. Your answer may lie on more spot on CPTs such as 43255 and critical care codes.

In the first scenario, the doctor injects epinephrine into a duodenal ulcer to control active bleeding during endoscopy with biopsy (43239). Earlier, you may opt to use 43239 added with modifier 22 if the physician required significant effort to control the patient's bleeding.

However this option would need you to submit additional paper documentation to support your modifier 22 claim. So instead if submitting yourself to potential hassles, you can correctly describe this session by reporting 43239 for the biopsy and 43255 for the control of bleeding provided that the bleeding was not caused by the biopsy.

As is obvious from 43255's descriptor, this procedure describes control of bleeding by “any method," including injection.

Necessity: On your claim, you should add modifier 59 to 43255, and then report 43239. If you leave out the modifier, it would give payers the impression that the biopsy (or physician) caused the bleeding and bundle 43255 into 43239.

In the second scenario, when the gastroenterologist is about to carry out an upper GI endoscopy, the patient undergoes very severe gastrointestinal bleeding; so much so that the physician must suspend the endoscopy and spend 40 minutes lavaging blood from the gastro-intestinal tract before continuing.

Report it: This time round, the critical care code 99291 is your best choice.

Here's why: if the gastroenterologist caused the bleeding, you can't bill for the control of bleeding procedure. You should ask control-of-bleeding codes only when treatment is required to control bleeding that takes place spontaneously or as a consequence of traumatic injury (noniatrogenic), and not as a consequence of another type of operative intervention.

You should bear in mind that the time spent at the bedside carrying out services including lavage of gastric blood isn't included in the performance of a subsequent endoscopic procedure and isn't part of the evaluation & management service that might be carried out on the same day.

Nonetheless, you should not report a critical care code carelessly for an excessive bleeding situation that is not out of the ordinary. Extra time for emergency bedside services less than 30 minutes does not count as billable critical care service. For prolonged critical care services, the doctor should exclusively note the amount of time in his notes.

CPT & ICD-9 guidelines to help your dysphagia evaluation and treatment

With so many coding changes taking place at regular intervals, coding for your gastroenterology coding practice is never easy.

You are constantly surrounded by tough coding situations and tough questions and answers. If you have queries on coding and reimbursement of dysphagia evaluation and treatment, here are some common concerns to help your understanding.

There are six ICD-9 codes that you should use to diagnose dysphagia. ICD-9 codes that are commonly used by practices to provide an appropriate dysphagia diagnosis are 787.20, 787.21, 787.22, 787.23, 787.24, 787.29.

Gastroenterologists should report 438.82 coupled with an additional code from the 787.20, "787.29 series for dysphagia due to the late effects of cerebrovascular disease. Reporting the combined ICD-9 codes should identify the specific type of dysphagia, if proper.

As far as CPT codes for dysphagia-related services are concerned, you should report these codes: 92526, 92610, 92611, 92612, 92614, and 92616. But then for most gastroenterology practices, 92526 is the only choice while reporting treatments associated with dysphagia related to any of the upper throat mechanics, as per the National Government Services LCD.

What’s more, the CCI prohibits combining 92526 with other CPTs when the focus of the treatment is for swallowing. For example, you should never use the 97xxx series of codes while billing for dysphagia treatment. Other codes that you will not be able to use with 92526 are 92511, 92520, 97032, 97110, 97112, 97150, 97530, 97532, among others.

And what about restrictions CCI has imposed on dysphagia treatment codes? CCI edits on dysphagia-related services prevents billing the codes together or requires using modifier 59 to indicate that they are distinctly separate procedures.

Report Appendectomy Separately Depending On What The Situation Demands

So you think appendectomy always comes bundled with other procedures. If so, you need to think again. You can report appendectomy separately depending on what the situation demands. If you miss your appendectomy codes, you could be losing your deserved payments.


Many people are of the false notion that skipping appendectomy codes has no bearing. Whereas the fact is if you fail to report 44955 when the situation demands, you would be costing your practice $83.58 (2.46 relative value unit times the 2011 conversion factor of $33.9764).


Familiarize yourself with these two requirements for separate appendectomy:


a) Your surgeon clearly documented a problem with the appendix


b) Other procedures during the same session do not relate directly to the right colon. When your gastroenterologist carries out a medically necessary appendectomy at the same time as another procedure, you would use +44955 (reported in addition to the primary procedure performed).



Using 44955 follows that you code a diagnosis to prove that the procedure was medically necessary.


Clue: If you cannot find an appropriate diagnosis code to support 44955, there are chances that the removal wasn't required because of immediate health concerns, and you shouldn't be separately reporting the appendectomy after all. Your answer to supplying a separate ICD-9 for 44955 lies in the CPT's descriptor, which includes the phrase “indicated purpose. This means that there must be a separate, medically necessary diagnosis or signs and symptoms to justify the appendectomy.


Here's an example: The patient has a gallbladder problem, and while carrying out the gallbladder removal, the surgeon finds acute appendicitis as well; as such he carries out an appendectomy. In this instance, you should use 44955 as well as the cholecystectomy. (for instance 47562, Laparoscopy, surgical; cholecystectomy). Also, you should bill 540.9 (Acute appendicitis without mention of peritonitis) to support your claim.


Physician's notes suggest you should scoop up info from path report


Also, you can take a look at the applicable signs and symptoms or the pathology report to verify your diagnosis code(s). See to it that your codes are supported by both your physician's documentation and your path report.


Even if the pathology report turns out to be negative for appendicitis, you can still report 44955 as long as the physician's documentation clearly states the reason he is removing the appendix.

E/M Coding: Learn The Importance Of The Eight-Hour Rule

Clue: Don't use discharge code 99217 in all observation situations.

Oftentimes, deciding on what observation code to use can be a challenge, more so because you have to look into two sets of this type. While one set (99234-99236) pertains to the care provided on a single calendar date, another set concerns care that spans two calendar dates (99218-99220).

Figure out the criteria for observation codes' use for physician services by looking closely into these three fallacies.

Fallacy 1: Observation services support extended inpatient care

You'd want to ensure –first and foremost – that the service is carried out by your gastroenterology qualifies as an observation. The doctor should opt for observation services to potentially prevent a lengthy inpatient admission. For example, an observation status is proper when:

The encounter lacks diagnostic certainty, where a more spot on diagnosis could decide admission or discharge.

The patient's condition calls for extensive therapy in order to possibly be abated.

Fallacy 2: Document, one more paperwork

The doctor's notes on the encounter would tell you how many calendar days the observation service lasted.

Consider the previous scenario: Say for instance the gastroenterologist admits the patient to observation at 9 p.m. on Wednesday. The doctor orders blood tests to check the patient's enzyme levels and performs a hydrogen breath test (91065, Breath hydrogen test [e.g., for detection of lactase deficiency, fructose intolerance, bacterial overgrowth, or oro-cecal gastrointestinal transit]) in order to check for any traces of bacterial overgrowth. The consequences of both tests turn out normal. For monitoring, the doctor keeps the patient overnight. Her notes point to a level two observation.

You would report the Wednesday services with 99219. 99219. What's more, another key component of coding multi-calendar date observation codes is reporting 99217 on the date of discharge service. Connect 789.00 and 787.01 to both CPTs to describe the patient's symptoms.

Report 99218-99220 for all the care rendered by the admitting physician on the date the patient was admitted to observation.

For the documentation requirements, the CMS Claims Processing Manual points out that a doctor can bill the initial observation care codes, provided he completes a medical observation record for the patient. This record should have dated and timed admitting orders of the physician, and reflect the care the patient gets while in observation, nursing notes, and progress notes arranged by the physician while the patient was in observation status.


Fallacy 3: Same-day observation codes require a discharge code

How about your gastroenterologist admits a patient to observation status and discharges him on the same calendar date? Then you would code 99234-99236. In this case, you would not have to code the 99217 discharge code. CPT allows the use of 99217 “if the discharge is on other than the initial date of ‘observation status'," as mentioned on the code's descriptor.

Same-day observation services 99234-99236 include documenting the time of the visit in hours (with a minimum of eight hours documented on the same calendar date, also referred to as the eight-hour rule).

Do 569.3 and 578.1 function the same way?

As a just-in gastroenterologist coder, sometimes you may run into rough weather or be confused about which code to use for a particular service.

For instance, a just-in coder was confused about when to use 569.3 and 578.1 for bloody stool? She was trying to figure out if they are one and the same.

Well, the answer is no. When you examine the stool, you would be able to decide on the original source of the bleeding. After that you would be able to select the proper ICD-9 code.

Blood in the stool originates from somewhere up the gastrointestinal tract. In this situation, you would use 578.1 (Blood in stool). On the contrary, traces of bright red blood on the outside of the stool or on the toilet tissue normally takes place from a source within the rectum or anus (569.3, Hemorrhage of rectum and anus).

While coding for a colonoscopy (45378), you would normally report 578.1 with 792.1 (Nonspecific abnormal findings in stool contents). A number of carriers do not accept rectal bleeding as a justifiable diagnosis for colonoscopy as they presume that the source of the bleeding is the rectum or anus, not the colon. But then, they accept rectal bleeding as an acceptable diagnosis for a flexible sigmoidoscopy (45330, Sigmoidoscopy, flexible; diagnostic, with or with no collection of specimen[s] by brushing or washing [separate procedure]).

Here's a hint: The gastroenterologist would opt for a colonoscopy if the flexible sigmoidoscopy does not reveal a source of the bleeding. The source could lie past the splenic flexure, which is only visible through a colonoscopy.

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