Gastroenterology Coding Alert

Help your office get paid when doc makes your job easier.

Coders ask questions all the time they could have answered easily, if only the physician had written his endoscopy report in language a coder understands.

Some doctors just aren't fluent in Coderese. They know what belongs in a report from a medical standpoint, but they're not always thinking in a reimbursement frame of mind. Here are a handful of tips to help you teach your physician our ways. If your physicians follow these simple guidelines when writing up their endoscopies, the whole office will save time and trouble.

1. Don't Skimp on the Polyps

Did your gastroenterologist remove several polyps? Or biopsy one and destroy others?

The phrase "multiple polypectomies" confuses the issue and doesn't give you enough information to code. Your physician needs to get in the good habit of detailing where the polyps were and what method he used to deal with them.

"Be specific about the method and the location of polyps being removed," says Tina Smith, CPC, CPC-H, CPC-I, CGCS, CHCA, a coding consultant with Coding Sense, LLC, of Craig, Colo.

If your physician removes polyps from different sites and uses different methods, or if he performs a biopsy of one lesion and removes another, you may record -- and bill -- more than one procedure. But that's not possible if he doesn't give you the details in the endoscopy note.

Example: Your physician performs a colonoscopy with tumor removal by hot forceps, followed by removal of polyps by snare technique. As long as your physician documents the lesions were on separate sites, and because neither endoscope is the base procedure (45330), you may report both procedures:

• 45385 -- Colonoscopy, flexible ...; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique

• 45384 -- Colonoscopy, flexible ...; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery.

Medicare payers will reimburse the full value of the more extensive procedure (in this case, 45385, with 13.85 physician work relative value units [RVUs]). Medicare will also pay the value of the second scope minus the value of the base procedure.

Typically, you'll report the less extensive procedure with modifier 59 to show the payer you're reporting a separate lesion and separate technique.

"We are reminded in the modifier 59 verbiage that if there is another modifier that is more appropriate, we should use it instead of a 59, but for what we're using it for ... there is no better modifier indicating a separate lesion," says Jill M. Young, CPC-ED, CPC-IM, president of Young Medical Consulting LLC in East Lansing, Mich.

Tip: You may need to append modifier 51 (Multiple procedures) to the less extensive procedure, 45384. Many payers no longer require modifier 51. Processing claims electronically allows the payer to recognize when your physician performs multiple procedures and automatically makes the necessary reduction in payment.

2. Make at Least 2 Diagnoses

Make sure you've got a pre-op and post-op diagnosis.

If the endoscopy is negative, go back to the original reason for the procedure as the diagnosis for the endoscopy.

Why you need both: You'll link the definitive finding, if any, to the procedure. You may link the pre-op diagnosis to an E/M with modifier 25, if your physician performs a significantly separate and identifiable service apart from the endoscopy.

Example: For instance, an established patient reports with difficulty swallowing. Your gastroenterologist performs a level-three E/M service and decides to perform an esophagoscopy with a balloon dilation and determines the patient has esophageal reflux.

You'd link the preoperative diagnosis, 787.24 (Dysphagia, pharyngoesophageal phase) to 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 ...) Then you'd link the postoperative diagnoses, 787.24 and 530.81 (Other specified disorders of esophagus; esophageal reflux) to the procedure, 43220 (Esophagoscopy, rigid or flexible; with balloon dilation [less than 30 mm diameter]).

Good advice: Always read the whole op note. Don't be tempted to only read the pre-op and post-op diagnoses and the type of operation the physician performed -- you can easily miss details and other billable services the doctor did not include in the summary.

3. Get Specific About Anemia

Most Medicare payers won't accept 285.9 (Anemia, unspecified) to support colonoscopy or EGD. Your physician should be specific about iron deficiency anemia substantiated by iron studies.

There are many types of anemia, which is an abnormally low level of healthy red blood cells or hemoglobin, the component of red blood cells that delivers oxygen to tissues throughout the body. One type of anemia is iron-deficiency anemia. One cause of iron-deficiency anemia is blood loss.

If your gastroenterologist is performing an endoscopy due to a patient's anemia, he should have some lab work that tells him it's an iron-deficiency anemia that suggests their Web sites. Insurers consider many symptoms justification for a lower GI endoscopy.

Here's a sample list of anemia diagnoses that support medical necessity for EGD procedures from National Government Services, a Medicare contractor:

• 280.0 -- Iron deficiency anemia secondary to blood loss (chronic)

• 280.8 -- Other specified iron deficiency anemias

• 280.9 -- Iron deficiency anemia, unspecified

• 281.0 -- Pernicious anemia

• 285.1 -- Acute posthemorrhagic anemia.

4. Know Your CRC Risk Factor

If your patient is having colonoscopy screening because of family history, please indicate relationship on the report. Why? It has to be a first-degree relationship:sibling, parent, or child.

The American Cancer Society says a patient may be at a increased risk of colorectal cancer if any first-degree relative before age 60, or two or more first-degree relatives at any age, had colorectal cancer or  adenomatous polyps.

The correct procedure code for a screening colonoscopy is G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) and the primary diagnosis should be V16.0 (Family history of malignant neoplasm; gastrointestinal tract).

Patients with one first-degree relative who has colorectal cancer experience double the risk of developing CRC; those with two or more relatives have quadruple the risk, according to a 2006 issue of the European Journal of Cancer.