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 Healthcare Resource Management Inc., a physician practice management consulting firm in Spring Lake, N.J.

Auditors Worksheet Can Simplify Coding

Because quantifying the level of medical decision-making can be difficult, many gastroenterology practices use the method employed by Medicare auditors. This method, summarized in the E/M Documentation Auditors Worksheet compiled by the Medical Group Management Association, assigns a point system to the remaining two components of medical decision-makingnumber of diagnoses/treatment options involved and the amount of data reviewedand then arrives at a score to determine the overall level of decision-making.

According to this worksheet, a problem that is new to the examining gastroenterologistwhich is likely to be the case in most consultationsis assigned three points, which is enough to qualify as a multiple number of diagnoses or treatment options. This score, in combination with the ordering of an endoscopic procedure, is probably enough to establish a moderate level of medical decision-making.

An established problem that is worsening is assigned two points, which only qualifies as a limited number of diagnoses, according to the E/M auditors worksheet. If the patient has co-existing conditionssuch as heart disease, diabetes or hypertensionthat affect medical decision-making, however, then those can be counted as separate secondary or additional diagnoses. Gastroenterologists tend to forget to write down all of the relevant diagnoses involved, says Brink. Those secondary diagnoses, if they contribute to the overall medical decision-making, should be documented and included in the consideration of the level of medical decision-making.

A secondary diagnosis that is either stable (worth one point) or worsening (two points) in combination with an established problem that is worsening (two points) will yield a score of three or four points, which is enough to be considered a multiple number of diagnoses. Again, this score, in combination with the ordering of an endoscopy, would probably qualify as a moderate level of medical decision-making.

Quantify the Amount of Data Reviewed

The amount and/or complexity of data to be reviewed also can be considered when determining the level of medical decision-making. The E/M auditors worksheet assigns points in this category as follows:

Review and/or order of clinical lab tests (one point)
Review and/or order of tests in the radiology section of CPT (one point)
Review and/or order of tests in the medicine section of CPT (one point)
Discussion of test results with the physician performing the tests (one point)
Decision to obtain old records and/or obtain history from someone other than the patient (one point)
Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider (two points)
Independent visualization of image, tracing or specimen itself (not simply review of report) (two points)

A total of three points is necessary to qualify for a moderate level in this category.

History and Examination Need to Be Noted

Once the level of medical decision-making has been established as at least moderate, a consultation or new patient office visit also will need a comprehensive history and a comprehensive level of examination to qualify for a level-four E/M service. An established patient office visit requires either a detailed history or detailed examination to qualify as a level-four service.

When an endoscopic procedure is being ordered, the level of history and examination performed likely will be in line with the level of medical decision-making. Both Littenberg and Brink agree that most gastroenterologists who order a diagnostic endoscopy at the end of a consultation or new patient office visit probably will have done the requisite comprehensive history and examination in order to get to that diagnosis. Most gastroenterologists will end up having a diagnosis that correlates to the chief complaint of the patient and the systems that were examined during the visit, says Brink.

With established patient office visits, however, gastroenterologists frequently forget to update histories or examinations done in previous encounters. Gastroenterologists dont document enough when it comes to interval history, Brink says. If they dont make a note of the interval history or have a necessity to perform an examin-ation during a follow-up visit, then the visit will not qualify as a level-four E/M service even if they do order an endo-scopy because all they did was medical decision-making.

Most gastroenterologists usually will do an interval history of a patient with a chronic problem, says Littenberg; it is just a matter of documenting it in the patients record. If the patient says in a previous visit that he smokes, explains Littenberg, the gastroenterologist will revisit that area of personal, family and social history in a follow-up visit and ask the patient if hes still smoking. Any change or lack of change needs to be noted.

Although a gastroenterologist should consider whether an office visit that results in the ordering of an endoscopic procedure is a possible level-four E/M service, not all of these visits will qualify. If a patient with chronic diarrhea and abdominal pain returns to the office with the same problems, notes Littenberg, and all you say is Lets do the colonoscopy like we discussed the last time, then that visit isnt going to be a level four. You must also have a detailed level of history.

Time Also Can Be a Determining Factor

Face-to-face counseling and coordination of care taking up more than 50 percent of the visit is another situation when reporting a level-four office visit often is appropriate. In that situation, the CPT says that time may be considered the key or controlling factor to qualify for a particular level of E/M service instead of the level of history, examination and medical decision-making.

The CPT estimates that a level-four established-patient office visit typically will take 25 minutes. If counseling and coordination of care takes up 15 minutes or more of a
25-minute office visit, according to Littenberg, that alone would qualify it for a level-four office visit. Such activities would have to take up at least 50 percent of a 45-minute new patient office visit or a 60-minute outpatient consultation to qualify those encounters as level-four E/M services.

Face-to-face counseling and coordination of care frequently will be a factor in visits with patients who have chronic conditions such as irritable bowel syndrome (564.1), Crohns disease (555.9) or gastroesophageal reflux disease (GERD), says Littenberg. Not only will the initial visit be dominated by counseling and coordination, but follow-up visits as well, he notes. The gastroenterologist will discuss why the patient has the condition, what the long-term treatment options are, how the patient is responding to medication and how the patient can modify his or her diet and lifestyle.

Documentation for this type of E/M service centers on recording the amount of time spent counseling the patient. Its critical to note the time spent counseling the patient and the time spent on the whole visit, explains Littenberg.

You can order copies of the E/M Documentation Auditors Worksheet from the Medical Group Management Association by calling (303) 397-7888.