Gastroenterology Coding Alert

Find out whether you can code the consultation and procedure.

Gastroenterologists often see patients who were referred by their general practitioner (GP). Sometimes a simple consultation turns into a same-day procedure.

Here’s a case study involving a suspected case of gastric intestinal metaplasia. Whether you’re new to coding or consider yourself a seasoned pro, here’s a case study to walk you through coding such a situation.

The case: The gastroenterologist recently saw a new patient who was referred by their GP. The patient was suffering from fatigue, loss of appetite, persistent indigestion, unexplained weight loss, and black, tarry stool. During the consultation, the gastroenterologist decided the patient needed an esophagogastroduodenoscopy (EGD), which the doctor performed that same day. And based on the stomach lining appearance took biopsies to check for signs of gastric intestinal metaplasia and dysplasia.

Condition refresh: Gastric intestinal metaplasia is a condition where the cells lining the stomach transform into cells that resemble those of the intestines. This is often a response to chronic inflammation, such as from Helicobacter pylori infection or other irritants. It is considered a precancerous condition because it increases the risk of developing gastric cancer. When dysplasia is present, it means that there are abnormal changes in the size, shape, and organization of the mature cells and glands of the stomach lining. This can be a precancerous condition, as it may progress to cancer if not treated or monitored properly. On the other hand, if dysplasia is not present, it means that while the cells have changed to resemble those of the intestines, they have not yet shown abnormal changes that suggest a progression towards cancer. However, it’s still a condition that may require monitoring because it increases the risk of developing gastric cancer.

Report the Consultation and the Procedure

Common confusion around a scenario like this revolves around whether you can code the consultation in addition to the procedure. The answer is yes, you can.

Keep in mind also, that since the patient has only been evaluated by their general practitioner, the gastroenterologist should establish and document a definitive diagnosis (or exclusion) prior to advising treatment.

The definitive diagnosis is not yet available; however, for the sake of this case study, let’s assume that the gastroenterologist was able to rule out at least one other, less severe, diagnosis. You’ll report the appropriate consultation code along with the EGD CPT^® code. Depending on the specifics of the consultation, as written in the medical notes, as well as the associated medical decision making (MDM) level, you may assign either of the following evaluation and management (E/M) codes:

• 99243 (Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.)
• 99244 (… 40 minutes must be met or exceeded.)

The counterpart codes for Medicare or payers who don’t recognize consultation codes would be 99203/4 (Office or other outpatient visit for the evaluation and management of a new patient… low/moderate level… 30-44/45-49 minutes…) for a new patient.

Modifier alert: To indicate to the payer that the E/M code was separately identifiable and not just the “usual” pre-procedure work, the 25 modifier (Significant, separately identifiable evaluation and management service by the same physician…) is appended to the E/M code. If necessary, remind the doctor to provide sufficient documentation along with this. “We need a robust paragraph of evaluation and management,” says Jeffrey Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA, principal, Lehrman Consulting LLC, Fort Collins, Colorado, during his HEALTHCON presentation, “What Exactly Is a Significant and Separately Identifiable E/M?”

Then, you’ll need to assign the appropriate EGD code, such as 43239 (Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)) to report the procedure.

Report the Relevant ICD-10 Codes

Even though the physician may be able to provide a preliminary report immediately following the procedure, and those suspicions and observations may show up in the medical record right away, you’ll need to wait for a more detailed analysis before assigning definitive diagnosis codes. “While documentation may show differential diagnoses that may end up being accurate, the coder cannot interpret the patient’s condition. It must be clearly stated by the treating provider(s),” explains Kelly Shew, RHIA, CPC, CPCO, CDEO, CPB, CPMA, CPPM, CRC, documentation and coding education, Olympia Medical in Livonia, Michigan. This is especially probable in this case because the tissue was biopsied, which needs to be sent for close inspection, which can take several days.

However, in order to prove medical necessity for the procedure, and to accurately record the encounter, you’ll need to report the patient’s symptoms:

• Fatigue: R53.83 (Other fatigue)
• Loss of appetite: R63.0 (Anorexia)
• Indigestion: K30 (Functional dyspepsia)
• Unexplained weight loss: R63.4 (Abnormal weight loss)
• Black, tarry stool: K92.1 (Melena)

Remember: These symptoms can also be associated with other gastrointestinal conditions, so even though we are assuming the doctor ruled out at least one explanation for these symptoms, it’s important to report all signs and symptoms at this stage. The patient’s experiences provide valuable clues to the underlying condition, and the doctor will need to refer back to these, and so might the payer or a future auditor.

Look at the Gastric Intestinal Metaplasia Codes

When the pathology comes back, you’ll need to code for the condition if the culprit is, in fact, gastric intestinal metaplasia.

The codes you will need to zero in on live in the K31.A- (Gastric intestinal metaplasia) category, with separate options depending on whether the patient has dysplasia or not.