ASGE members may submit coding inquiries electronically to codingquestions@asge.org. Each month ASGE gets dozens of questions from members. When submitting a question, please allow at least 3 business days for a response. When submitting inquiries, please include the ASGE member’s name and ID number. Only questions will be accepted and not reports. Full patient and practice information is a violation of HIPAA privacy rules and questions will be sent back without an answer.
Question #1
Why are payers not automatically paying for snare and biopsy? I use the 59 modifier on the biopsy.
Answer #1
Unfortunately, these two codes are often denied/pended even with the appropriate modifier. For the claim to be paid, it will have to be appealed. The payer is looking for documentation to include a separate lesion treated with a separate technique which includes the instrument used to treat the lesion(s). If that information is not contained within the endoscopy report, the payer will most likely only pay for one technique. Use of the XS modifier in place of modifier 59 also is recommended since that modifier is more specific and is also accepted by the majority of commercial payers, not just Medicare. It is also important to link the diagnosis as well as enter locations into the comment field (Box 19) for each technique to support "separate lesion" designation. For supporting documentation, please refer to NCCI policy, chapter 6, section H, #25 which states:
The NCCI PTP edit with column one CPT code 45385 (Flexible colonoscopy with removal of tumor(s), polyp(s), or lesion(s) by snare technique) and column two CPT code 45380 (Flexible colonoscopy with single or multiple biopsies) is often bypassed by using modifier 59 or -X{EPSU}. Use of modifier 59 or XS is only appropriate if the two procedures are performed on separate lesions. Use of modifier 59 or XE is only appropriate if the two procedures are performed at separate patient encounters.
Question #2
What diagnosis code do I submit as primary when a patient that is 25 and being screened for colon cancer because a first-degree relative has a history of rectal cancer?
Answer #2
Because of the patient’s age, there are two different answers to this scenario depending upon payer policy. You can either use Z12.11 (average risk screening) and Z80.0 (family history of colon cancer). ICD-10-CM recommends that average-risk screening be submitted in the primary position with a family history of colon cancer as secondary. However, computer edits can automatically deny the claim based upon the age of the patient when Z12.11 is submitted as the primary diagnosis. Utilization of the comment field (Box 19) and enter the relative and the age of diagnosis.
Example: Father diagnosed with rectal cancer at age 35. Whether you use Z12.11 or Z80.0 as the primary diagnosis, utilization of the comment field is essential. Keeping a spreadsheet of payer preferences is also essential to reduce denials/pends on the claim.