EM Coding Alert

Question: A high-risk patient came in for a screening colonoscopy to our gastroenterologist. During the encounter, the GI noted that the patient also consulted the physician for an acid reflux problem. The GI then proceeded to ask questions about the patient’s history with these acid reflux symptoms, performed an examination and put the patient on a prescription to treat the acid reflux condition. How should I code this encounter? Can I report a separate E/M for the visit?

Connecticut Subscriber 

Answer:  You should use two diagnosis codes to report for the gastroenterologist’s visit: one for the family history of colon cancer (V16.0, Family history of malignant neoplasm of gastrointestinal tract, [ICD-10: Z80.0, Family history of malignant neoplasm of digestive organs]) and the other for acid reflux (530.81, Esophageal reflux, [ICD-10: Gastro-esophageal reflux disease without esophagitis]).

If the screening colonoscopy is performed on the same day as the initial encounter, you should report G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) if this is a Medicare patient and use 45378 if the patient is not a Medicare patient assuming that there were no therapeutic procedures performed during the procedure. 

The gastroenterologist can bill for a separate E/M service as the primary reason for the visit was different from the second ailment presented. However, you will have to attach modifier 25 (significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service) to the E/M code and a related diagnosis code (530.81). For E/M, you can use from the office visit codes (99201-99205, New patient office or other outpatient services) if the patient is new and from 99212-99215 (Established patient office or other outpatient services) for established patients.

You will have to support your claim that the separately billed E/M service was clearly significant and separate from the endoscopic procedure. You should be very meticulous about making certain your physician understands the documentation requirements and the following information in the documentation would be very helpful:

• different diagnosis codes for the E/M service and the endoscopic procedure (not always required, but necessary in this instance);

• different examination elements that correlate to the patients various complaints;

• and a treatment plan, such as the ordering of medication or a different endoscopic procedure that specifically addresses the patients other complaint.

Caution: You cannot bill an E/M service if the gastroenterologist’s treatment plan consists of scheduling a separate appointment for discussing the second complaint. He should have provided some sort of medical decision-making in order to bill for an E/M service.