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Gastroenterology Coding Alert

E/M Coding:

Can You Code These GI-Focused E/M Case Studies?

Published on Tue Mar 16, 2021

Check your E/M coding skill to ensure you’ve got the 2021 guidelines down pat.

Now that gastroenterology coders have gotten accustomed to using the new office/outpatient E/M coding guidelines, it’s probably become second nature to bill your services using these rules. To ensure you’re applying your newfound knowledge accurately, test yourself by checking out three GI-focused E/M scenarios and determining if you can select the right codes.

Example 1: MDM Or Time?

The situation: The GI physician’s note states, “Patient with long-term established colostomy presents with complaint of redness and pus from the ostomy site. Reviewed history from Jan. 21, 2021 visit and remarkable changes include redness and yellowish secretions from the ostomy site. Normal heart and lung sounds, pulse 78, temperature 98.9, blood pressure 146/82, abdomen soft, no swelling in extremities, noted general pallor. Ordered culture of colostomy secretions, cleaned and replaced colostomy tube. Spent 25 minutes with the patient and discussed infection management, ways to keep the ostomy site free from bacteria, and medication management options.”

The solution: How you’ll code this visit will depend on the level of medical decision making (MDM) in the documentation or the time spent. Because the physician spent 25 minutes, you can report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter) based on that.

To report 99213 without using time, you’d need to document two of the following three components:

  • The number and complexity of problems (two or more minor problems, or one stable chronic illness, or one acute, uncomplicated illness or injury)
  • The amount or complexity of data reviewed and analyzed (reviewing prior external note(s), reviewing test result(s), and/or ordering unique test(s)) OR (assessment requiring independent historian(s))
  • Low risk of complications and/or morbidity or mortality of patient management

The note in this example still earns 99213 by documenting the first and third of these elements, but more detail regarding amount and complexity of data in this case would ideally be beneficial.

Pointer: In this example, the time referenced was time actually spent with the patient, which might not be the total time the day of the encounter, says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT® Editorial Panel member in Pasadena, California. “It is possible the physician could have taken credit for other time not directly with the patient; but if it isn’t documented, any auditor would consider it wasn’t done,” he notes.

Example 2: Detail Without Substance

The situation: The GI physician’s note states, “A 23-year-old new patient referred from the local emergency department (ED) presented for management of pain in the esophagus following a minor car accident. The patient reports 4 on a pain scale of 10. The pain actually appears to be coming from a neck sprain rather than from a GI problem, and no GI issues seem to be present. Patient denies any diarrhea, gas, nausea, dizziness, lightheadedness, or regurgitation, and says that she is generally healthy. Her weight, blood pressure, and pulse appear to be WNL [within normal limits]. I suggested that if the pain continues, she sees an orthopedic physician about her neck pain.”

The solution: Because the gastroenterologist didn’t indicate the amount of time spent during the encounter, your only choice is to report the visit based on the MDM. Although the note has some important details in it, it doesn’t support a high level of MDM. In this case, the documentation describes straightforward MDM, which requires the following:

  • One self-limited or minor problem
  • Minimal or no data to be reviewed and analyzed
  • Minimal risk of morbidity from additional diagnostic testing or treatment

Therefore, you should report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter).

Example 3: MDM Matches Time

The situation: The GI physician’s note states, “An established 25-year-old female patient with a previously confirmed diagnosis of celiac disease reports moderate pain when she swallows, which she rates as a 6 on a scale of 1 to 10, and diarrhea three times a day, both of which she has had for a week. The patient denies adding anything new to her diet, and has no nausea, vomiting, fever, chills, dizziness, or lightheadedness. Ordered an upper GI, which she will return for in two days. Spent 30 minutes total with the patient discussing nutritional management, medication adherence, and what types of ways she can manage the diarrhea.”

The solution: Based on both MDM and time, the best code for this documentation would be 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter).

Not only did the provider spend 30 minutes with the patient, but they also performed two out of the three required MDM elements to qualify for moderate MDM:

  • One or more chronic illness with exacerbation, progression, or side effects of treatment
  • Tests, documents, or independent historian(s)
  • Moderate risk of morbidity from additional diagnostic testing or treatment

Therefore, in this case, you’d report 99214 no matter which method you use.

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