When you are coding for excessive blood loss, modifier 22 may not be what you are looking for. The answer may depend on more appropriate CPTs such as 43255 and critical care codes.

Think about endoscopy with injection as option

Scenario 1:

The physician injects epinephrine into a duodenal ulcer to control active bleeding during endoscopy with biopsy. 43239, Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as apt; with biopsy, single or multiple).

Previously, you may opt to use 43239 appended with modifier 22 (Increased procedural services) if the doctor required effort to control the patient’s bleeding.

However this option would need you to submit additional paper documentation to support your modifier 22 claim. Instead of submitting yourself to potential hassles, you can accurately describe the 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.

Requirement: On your claim, you should append modifier 59 to 43255, and then report 43239. Omitting the modifier would give payers the impression that the biopsy (or physician) caused the bleeding and bundle 43255 into 43239.

Extraordinary bleeding requires critical care coding

Scenario 2: When the gastroenterologist is about to carry out an upper GI endoscopy, the patient experiences gastrointestinal bleeding so severe that the doctor must suspend the endoscopy and spend 40 minutes lavaging blood from the gastro-intestinal tract before continuing.

Code it: This time, the critical code 99291 is your best choice.

Here’s why” If the gastroenterologist caused the bleeding, you cannot bill for the control of bleeding procedure. You should call on control-of- bleeding codes only when treatment is required to control bleeding that occurs spontaneously, or as a consequence of traumatic injury (noniatrogenic), and not as a result of another type of operative intervention, the CPT Assistant states.

Remember 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 is not part of the E&M service that might be carried out on the same day.

Nevertheless, you should not report a critical care code carelessly for an excessive bleeding situation that’s not out of the ordinary. Additional time for emergency bedside services less than 30 minutes does not count as billable critical care service. For prolonged critical care services, the physician should specifically note the amount of time in his notes.