EM Coding Alert

Question: We reported 99213 as well as the colonoscopy screening code G0121, and we used modifier 25 on the E/M code. Our payer used to reimburse us for this but we’re now seeing denials. Should we appeal?

Utah Subscriber

Answer: Probably not. If your gastroenterologist frequently reports an E/M code (99201-99215) on to her screening colonoscopy services, check the documentation for notes that would support the E/M code — in most cases, this information is insufficient to report both an E/M and a colonoscopy.

For instance, you note that your physician reported 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity...) with most of her screening colonoscopies, such as G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).

Ask this:  When reviewing the documentation, ask yourself what the chief complaint is for the E/M visit. A patient presenting solely for the purpose of a screening colonoscopy would likely not have a chief complaint to report. In addition, see if you can find the location, timing, quality, context, duration, severity, associated signs and symptoms and modifying factors of the patient’s complaint. You are not likely to find any. Therefore, it’s clear that the documentation does not meet the medical necessity for an E/M service.

In addition, the Correct Coding Initiative does typically bundle these codes together. You note that you append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code, but you can only bill this way if you provide a separately identifiable and medically necessary E/M service. If the gastroenterologist is only seeing the patient for the screening colonoscopy and no other issues, your notes most likely do not support the use of this modifier.

Therefore, in most cases, for Medicare patients, you will not use the E/M code for your colonoscopy visits. The circumstances differ however for patients in commercial plans governed by the Affordable Care Act (rather than, for example, some ‘grandfathered’ plans such as plans offered through self-insured employers); in these circumstances, the Department of Labor issued guidance that patients are entitled to a pre-screening colonoscopy visit even in the absence of symptoms. Some plans expect use of E/M codes for outpatient office visits (99201-99205, 99212-99215, most typically at a lower level if there are no serious medical issues to be assessed or treated); some plans may expect a preventive care service; and some recognize only the Blue Cross Blue Shield code S0285. There should be no cost-sharing (deductible or copay) imposed by the payer.