Colonoscopy With Biopsy and AV Malformation

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September 19, 2013

Question:

I submitted a claim to a payor for a colonoscopy with biopsy of a polyp in the transverse colon and control of bleeding at the site of an AV malformation (original planned surgery). I submitted the following codes and received a denial (45382 and 45380) from Medicare. I resubmitted to Medicare with a modifier 51 and they denied indicating that the two codes were bundled. I do not want to use modifier 59 because Modifier 51 is the more appropriate modifier. If I send the claim with no modifiers, they will deny the claim. Can you please shed some light?

Answer:

Yes, we can help shed some light on this scenario. Modifier 59 is the correct modifier and the rationale is as follows.

Bleeding control at the site of the biopsy is included with the biopsy procedure itself (45380). To report CPT code 45382 (control of bleeding) at a site different (the AV malformation) and unrelated to the biopsy (45380) you must indicate to Medicare that the procedure for the control of bleeding was at a different location than the polyp biopsy. This makes modifier 59 the most appropriate (distinct procedure, separate surgery, different location).

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