Gastroenterology Coding Alert

Follow-up visits with patients after an endoscopy or test are often billed as a low-level E/M service. Those visits, which may be dominated by a review of test results and counseling, usually don't require a significant level of history, examination or medical decision-making. If the time spent face-to-face with the patient is used as the key component, gastroenterologists may be able to bill for a higher level of E/M service for follow-up visits. It is important that gastroenterologists document the counseling portion as well as the E/M portion of the visit so the service will not be downcoded during an audit. 

Because gastrointestinal endoscopy procedures have a global period of zero days, a gastroenterologist can bill for a follow-up office visit on a subsequent day, says Joel Brill, MD, a gastroenterologist in Phoenix and the American Gastroenterology Association's representative to the CPT Editorial Advisory Committee. The visit will probably be an established patient office visit (99211-99215) because the patient has previously received professional services from the gastroenterologist. With procedures such as an esophageal motility study or 24-hour pH monitoring, where the physician or another provider may have performed the test, the gastroenterologist may still bill a follow-up visit when discussing the test results with the patient as long it meets the requirements of an E/M service. 

Two sets of E/M guidelines followed by both CPT and Medicare apply to follow-up visits. The first is that for an established patient office visit, two of the following three key components must be present during the encounter: history, examination and medical decision-making. The other guideline is that when counseling and coordination of care dominates more than 50 percent of the physician/patient encounter, time may be considered the key or controlling factor in choosing a particular level of E/M services rather than the level of history, examination and medical decision-making.

 

 

Even when time is the controlling factor, the three key components of an E/M visit --history, examination and medical decision-making -- must still be documented in the patient's medical record. Only two of the three components are needed for established patient office visits. 

"Even if the visit is primarily for counseling and coordination of care, you can't throw out history, examination and medical decision-making," says Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc., a physician practice management consulting firm in Spring Lake, N.J. "You can't just write 'spent 35 minutes -- 20 minutes counseling patient' on the medical record. The auditor needs to know what you did for the other 15 minutes of the visit."

Brink recalls a chart she recently reviewed for a colonoscopy follow-up visit. The gastroenterologist's office had called the patient to say that there were no polyps, but she did have diverticulosis. The patient was asked to come into the office to discuss the results of the colonoscopy. "The note in the chart read 'Diverticulosis discussed. Long conversation ensued. Doesn't have to come back for five years,'" Brink says. "But there was no history, no exam and no diagnosis noted."

 

 

Even before those key components are documented, Brink says it is necessary to note the reason for the visit. "You always have to have a reason for the visit, or a chief complaint," she explains. "In this case, the reason would be 'follow-up visit to colonoscopy.'" 

After a reason for the visit has been established and documented, the gastroenterologist must document the medical necessity for the visit. Though the follow-up visit may consist primarily of reviewing test or endoscopy results and discussing treatment options, both Brink and Brill believe that most gastroenterologists are also taking some history information and performing some examination and medical decision-making services during those encounters. The key is to document what is going on during the visit. Because these are usually established patient visits, however, only two of the three components need to be considered.

 

 

In most cases, the history will be an interval history because the gastroenterologist has already taken a complete history during a previous encounter. "The question 'How are you doing?' is history-taking," Brill says. "If the patient replies that he or she had a little gas after the procedure, that's what should be documented for the history." 

If the patient's condition has not changed since the last visit, the phrase "No changes since last visit on May 1" is appropriate to qualify as history. Other items that may be part of the interval history include the patient's reactions to any medications taken, any new symptoms, a change in diet, or any changes in old symptoms. 

Brink stresses that even though the nurse may take the patient's vital signs, the gastroenterologist must document that he or she reviewed those vital signs with a phrase such as "Vital signs reviewed as noted." 

The examination during a follow-up visit will also be brief and probably limited. The standard practice with most gastroenterologists is that their nurse will take a patient's vital signs before the gastroenterologist sees the patient  even for a follow-up visit, according to Brill. "A nurse will do a blood pressure check, take a pulse and the patient's weight," he explains. "These are physical findings  even if the gastroenterologist never lays a hand on the patient during that visit, you still have documented physical exam findings." 

In most follow-up visits, the diagnosis and plan of treatment are part of the medical decision-making for that encounter. For example, in the case of the patient with diverticulosis, the gastroenterologist may decide that the patient only needs a change of diet or may decide that the patient needs medication. Both options are considered medical decision-making, according to Brink, and the gastroenterologist should outline what treatment is prescribed.

 

 

The remainder of the follow-up visit will usually be spent in counseling. According to CPT, counseling is a discussion with a patient and/or family concerning one or more of the following:

 

diagnostic results, impressions and/or recommended diagnostic studies;
 

prognosis;
 

risks and benefits of management (treatment) options;
 

instructions for management (treatment) and/or follow-up;
 

importance of compliance with chosen management (treatment) options;
 

risk factor reduction; and
 

patient and family education.

 

For time to be considered a key component, more than 50 percent of the time with the patient must be spent in counseling or coordination of care. In addition, gastroenterologists must clearly document what was discussed. "All too often when I have been asked to audit a chart I find that it will say, '15 minutes/10 minutes counseling' and that's it," Brill says. 

He suggests that in the case of the patient with diverticulosis, the following notation would be a more appropriate documentation: 

Visit lasted 15 minutes. 10 minutes spent in counseling.

 

"This note probably added 10 to 15 seconds to the time I spent documenting the visit," Brill says. "You just have to document the components or what was covered during the visit." 

Brink agrees that it doesn't take a lot of time to do thorough documentation. "You don't need to list all the questions that the patient asked  just that you answered the questions to show a verbal exchange," she says.

 

 

The final pieces of information that need to be documented are the total time spent in the visit and the time spent counseling, which are crucial if an auditor reviews the chart. While it is sufficient just to list the amount of time spent, Brink says that many practices are going a step further and recording start and stop times. "The chart may have blanks that the gastroenterologist fills in," she explains. "The notation would read '1:00 p.m. began visit, 1:10 p.m. began counseling, 1:20 p.m. ended visit.'"

 

 

For follow-up visits, the level of history, examination and medical decision-making will be fairly low. Brill estimates that the encounter with the diverticulosis patient would probably be a level-two office visit (99212) when based on those three components. The suggested time limit for a level-two office visit as stated in CPT is 10 minutes. If the gastroenterologist spends a total of 20 minutes with the patient and 15 minutes (or more than 50 percent) of that visit doing counseling, the level of visit can be based on time. In this case, a gastroenterologist could justify the encounter as a level-three office visit (99213) because the time limit for that level is at least 15 minutes. 

When time is used as the key component, Brink emphasizes, the total time spent face-to-face with the patient should be considered and not just the amount of time spent counseling. 

Not all follow-up visits -- particularly those with more complicated medical decision-making -- will be determined by the amount of time spent with the patient. For instance, instead of diverticulosis, the patient has a broad-based sessile polyp in the colon, part of which is shaved off during the colonoscopy and sent for a biopsy. The pathology report is indeterminate. 

In this case, the gastroenterologist has many more factors to consider as part of the medical decision-making, says Brill. Is the polyp cancerous, precancerous or benign? Should you do another colonoscopy? Do you send the patient for further studies such as an endoscopic ultrasound or a CAT scan or do you need to consider a surgical referral? "The level of medical decision-making is at least moderate," he says.

Depending on the level of history or exam that occurs during the visit, the gastroenterologist could be billing a level-three (99213) or level-four (99214) office visit. However, the gastroenterologist will probably spend nearly the same amount of time with the patient, 15 or 20 minutes, as he or she did with the diverticulosis patient, says Brill. 

Because the suggested time limit for a level-three visit is 15 minutes and a level-four visit is 25 minutes, time spent coordinating care and counseling will not be a factor in determining the level of this encounter. 

Both Brink and Brill agree that auditors frequently downcode the level of an E/M visit when it is based solely on time. However, that is usually because the necessary documentation to justify the time spent is not in the chart. "If you go by counseling to determine the level of visit," Brink says, "you have to document it clearly."