Gastroenterology Coding Alert

Gastroenterologists may be losing a significant amount of revenue by underbilling their consultations as well as other evaluation and management (E/M) services. An article making that claim appeared in a recent issue of the AGA News, a monthly publication of the American Gastroenterological Association. GI practices bill mostly level-3 consults that actually audit as level-4 consults, read the article, which went on to estimate that this underbilling could be costing gastroenterologists in busy practices as much as $20,000 a year.

Several coding experts agree that gastroenterologists should consider coding for a level-four E/M service in at least two common situations: when the visit results in the ordering of an endoscopic procedure and when a significant amount of time is spent on counseling and coordination of care.

Many gastroenterologists dont know what the borderline is between a level-three and a level-four visit, or they underdocument the patients medical record, says Glenn Littenberg, MD, FACP, a gastroenterologist in Pasadena, Calif., and a member of the American Medical Association CPT Editorial Panel.

Requirements of a Level-four Visit

Level-four consultations (99244), as well as new patient office visits (99204), require the following three components: 1) a comprehensive history, 2) a comprehensive examination, and 3) a moderate level of medical decision-making. Level four established patient office visits (99214) require only two of the following three components: 1) a detailed history, 2) a detailed examination, and 3) a moderate level of medical decision-making.

In determining what constitutes the moderate level of medical decision-making required for all level-four E/M services, the Health Care Financing Administration (HCFA) has established the following three criteria: 1) a multiple number of possible diagnoses and/or treatment options are involved; 2) a moderate amount and/or complexity of data is reviewed; and 3) a moderate risk of significant complications from either the patients problems or the treatment options or the diagnostic procedures ordered exists. Medicare requires that only two of the three criteria must be met or exceeded to qualify as a moderate level of medical decision-making.

The decision to perform an endoscopic procedure is frequently a signal that a moderate level of medical decision-making has occurred because HCFAs 1997 documentation guidelines on E/M services classifies the ordering of a diagnostic endoscopy with no identified risk factors as having a moderate risk of significant complications. And it is likely that the problems and conditions that led to the ordering of the endoscopy will be reflected in another element of medical decision-making, the number of possible diagnoses and/or treatment options.

Often the risk of significant complication is mirrored in and related to the number of multiple diagnoses and treatment options to be considered, says Catherine Brink, CMM, CPC, president of [...]