Gastroenterology Coding Alert

Ask 2 key questions to pick the right code--and the right level--every time

When reporting most E/M services, you-ll need to know two things: Is the patient new or established? What are the documented levels of history, physical exam and medical decision-making (MDM)?

Here are quick instructions on how to use this information to select the correct E/M level every time.

Face-to-Face in 3 Years Means Established Patient

Generally, you should consider a patient to be established if any physician in your group practice (or, more precisely, any physician of the same specialty billing under the same group number) has seen that patient for a face-to-face service within the past 36 months, says Marvel J Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver. A recent CMS transmittal (R731CP, change request 4032, implemented Jan. 3) reiterated and reinforced the agency's policy on new and established patients.

Location isn't the issue: If your practice has multiple locations and a physician in location -A- sees the patient in January and a physician at location -B- sees the patient in December, the patient is still established. The need to create a new chart is inconsequential, Hammer says.

For instance: A primary-care physician recommends that a 60-year-old male see a gastroenterologist for a full workup. One of the physicians in your practice interpreted some test results for the same patient the previous year but provided no face-to-face service.

In this case, you can still consider the patient to be new when selecting an initial E/M code because no physician within your practice provided the patient with a face-to-face service within the past three years, says Kathy Pride, CPC, CCS-P, a consultant with QuadraMed in Port St. Lucie, Fla.

Another example: A patient comes to your office with a complaint of extreme heartburn and stomach pains. Although this is Gastro A's first time meeting the patient, Gastro B, in the same group practice, saw the patient two years ago for a similar complaint.

In this case, you should consider the patient to be established.

Different Specialties Allow for Exceptions

The new-patient rule applies when physicians in the same practice are also of the same specialty, says Cindy Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga., and president of the American Academy of Professional Coders- National Advisory Board.

Translation: If your practice is big enough and covers enough specialties, two physicians may see a patient for completely different reasons, Parman says. This could allow you to report a new-patient visit even though two physicians in the same practice saw the same patient within a three-year period.

Example: A general surgeon in a large multiple-specialty practice sees a patient in 2004 to remove some skin lesions. In early 2006, the same patient sees your gastroenterologist--who is a member of the same multi-specialty practice as the surgeon who earlier treated the patient--for an inpatient consultation.

Because the surgeon and gastroenterologist (who are obviously of different specialties) saw the patient for completely unrelated problems (this is key), you may report the gastroenterologist's initial visit with the patient using the new patient codes, Parman says.

Select an E/M Range by Service and Patient Status

Once you-ve determined the patient's new or established status, you should use that information--along with the type of E/M service the physician provides--to select the appropriate E/M code range.

For example: The gastroenterologist provides an office visit for the patient described above with persistent heartburn and stomach pain. Because the patient has seen another gastroenterologist in the group practice within the previous 36 months, he is established.

To select an appropriate E/M code range, you should go to the -office or other outpatient services- portion of CPT and find the code range for established patients (99211-99215). This is the range from which you will make your final code selection.

Example 2: The same patient as above sees your gastroenterologist, but this time as an office consult at the request of his primary-care physician. You should check the -Office or Other Outpatient Consultations- portion of CPT. In this case, the consult codes do not differentiate between new and established patients. Therefore, you will make your code choice from the 99241-99245 range. 

New Patients, Consults Require All 3 Components

When reporting consults and new patient E/M services, you-ll need to meet the requirements of all three key components (history, exam and MDM) to report a given level of service. In effect, this means that whichever key component is the -lowest- will determine the E/M service level you choose, Hammer says.

The AMA added text to CPT in 2006 to clarify that all of the key components (history, exam and MDM) must meet or exceed the stated requirements to qualify for a particular level of service for office, new patient (99201-99205), initial observation services (99218-99220), initial hospital care (99221-99223), office consultations (99241-99245), initial inpatient consultations (99251-99255) and others.

Example: During an office visit with a new patient, the gastroenterologist documents a comprehensive history, a comprehensive exam, and low-complexity MDM. In this case, the physician has met the history and exam requirements for 99204 (Office or other outpatient visit for the evaluation and management of a new patient ...) but the MDM requirement for 99203.

Because the level of the lowest key requirement also determines the E/M service level for new patient office visits, you must choose 99203 in this case, Pride says.

Alternative example: During an initial inpatient consultation, the gastroenterologist documents a detailed history, a detailed examination, and moderate-complexity MDM. Because you have met or exceeded all three categories for a level-three service of this type, you should report 99253 (Initial inpatient consultation for a new or established patient ...).

2 of 3 Will Do for Most Established Visits

When reporting most established patient outpatient E/M services (except consults and observation care), you can assign an E/M level based on just two of the key components, Hammer says.

Example: The gastroenterologist sees an established patient with a new complaint. The physician documents an expanded problem-focused history, expanded problem-focused exam, and straightforward MDM. In this case, the MDM only meets the level of 99212, but because the other two components meet the requirements for 99213, you may report this higher-level service.
 
You must meet or exceed the stated require-ments for two of the three key components for established patient office visits (99211-99215), subsequent hospital care (99231-99233), subsequent nursing facility care (99307-99310) and others, according to CPT.

Remember: You can report E/M services based on time, rather than the key components of history, exam and MDM, if the physician spends more than 50 percent of the visit on counseling and/or co-ordination of care. Look to a future edition of Gastroenterology Coding Alert for complete information on coding E/M services by time.