Gastroenterology Coding Alert

Be aggressive with your procedure/diagnosis queries for the sake of clarity.

In diagnostic coding, transforming medical records into a numeric code for billing purposes may not be enough. Documentation is the basis for coding. Thus, you should take into consideration accurate documentation as critical to diagnostic coding.

Risk: Deficient documentation could result in a payer's refusal to reimburse for a test or service you rendered. Make sure you and your physician speak the same language, so you can code at the highest level. Here are two guidelines to do just that.

1. Ensure Clarity Between You And Your Physician

You should avoid 'ultraconservatism' in coding. Over the years, many coders have learned to break off from the practice of questioning the physicians when the documentation was not complete or was not clear to them. You and your physician should work hand in hand on going after better documentation -- as aggressively as you can.

While physicians should look at a patient's medical record from the perspective of how it will be coded, you -- as the coder -- must be prepared to ask the physician to clarify sections of the note to be sure you have done your job and coded the claim correctly.

"It is a difficult transition to get physicians to understand about what they have to put in a record for accurate coding versus what they need clinically. I think that is a real educational issue for them," says Carol Paret, chief community benefits officer, Memorial Hermann Healthcare System in Houston, Texas, during the 2002 Straight Talk series of group discussions on key issues in healthcare. This issue is still very much a valid one in today's circumstances. You and your physician should make it a point to bridge the gap between the physician language (the clinical language you read in the documentation), and the methodology you use as a coder.

Example: Take an incomplete endoscopic retrograde cholangiopancreatography (ERCP). Most ERCPs are not finished due to the gastroenterologist's inability to cannulate the ampulla of Vater because it's blocked or can't be found. A blockage further up in the patient's esophagus may also cause the procedure to be terminated. This issue has become difficult because there is no clear cut policy that tells you how far the endoscope has to advance like there is with a colonoscopy.  Some practices would agree to define an incomplete ERCP as one where the gastroenterologist cannot cannulate the ampulla of Vater. The physician should also be able to visualize either the bile or pancreatic ducts. All these details should be properly documented, agreed upon, and be clear with both physicians and coders. In this case, practices may agree to adapt the basics of Medicare's incomplete-colonoscopy policy, i.e., attaching modifier 53 (Discontinued procedure) to the diagnostic code 43260 (Endoscopic retrograde cholangiopancreatography [ERCP]; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), when reporting any kind of incomplete ERCP.

Narrative terms may be required to support key procedures and diagnoses. For instance, a patient may have gastric ulcer (531.x), but simply stating or documenting "ulcer" may not be specific enough to capture and reflect the severity of the patient's condition. Situations like this should prompt you query the physician (verbal or written) regarding the specific degree or type of ulcer that the patient may have.

2. Don't Expect Somebody To Do Coding For You

The task of appropriately documenting the medical record should fall mainly on the physician's responsibility. You, as coders, cannot just pluck out information from anywhere to support your codes. Any information on a procedure or diagnosis that you have to bill must come from the physician (or a certified healthcare provider), not anyone else. When you approach the physician to get clarification or to educate them about documentation principles you may first ant to remind them not to shoot the messenger.

Aim this: A good medical record will contain information about the reasons a patient sought the physician's help, relevant medical history, diagnostic test results, findings, medical assessment of clinical impression and diagnosis, and even well into the plan of treatment.