Gastroenterology Coding Alert

With the number of hepatitis C patients growing at an astounding rate, your practice may have to rely on physician assistants, nurse practitioners and clinical nurse specialists to provide appropriate care. That means you'll have to brush up on some new coding skills.

The diagnosis and individualized treatment plans for patients managed by general practitioners are often confirmed during consultations with a specialist such as a gastroenterologist. You need to know how to get the most out of these consults because they may consume much of your time.

According to CPT guidelines, a consultation is a service provided by a physician whose opinion or advice about a specific problem is requested by another physician or other appropriate source. There are several points to remember in order to get full payment for consultations:

The written or verbal request for a consultation must be documented in the patient's records.

The consulting physician must document his opinion in the records, along with services ordered or performed.

The consulting physician must document his findings to the referring physician in a written report.

It is appropriate to report a consultation code (99241-99255) when the consultative service is between the same specialty in the same group practice and the above criteria are met.

Do not get consultations confused with referrals. If the consulting physician is not in the same domain as the referring physician AND does not communicate his advice to the primary physician, then it is a not a consultation but a referral.

Remember that the consulting physician may initiate diagnostic or therapeutic services at the first or subsequent visits. When the consulting physician assumes responsibility for all of the patient's care, the E/M services provided after the initial consultations should be coded for the appropriate level of subsequent hospital care (99231-99233) or the appropriate level of office or other outpatient services (99211-99215). Any other follow-up consultative care should be coded 99261-99263 for inpatient and 99211-99215 for outpatient.

When a gastroenterologist is the primary caregiver for a hepatitis C patient, he assumes full responsibility for diagnosis, treatment and counseling. Patients often have to schedule regular office visits. Due to the long-term nature of these services, a variety of tasks are undertaken by PAs and/or NPs.

A typical visit consists of "a medical exam, lab reviews, medication adjustments, monitoring of side effects, and an investigation of social issues and depression factors. Also, physician assistants educate and train patients on how to self-administer their own injections at home," says Teresa L. Baker, CPC, physician billing manager for the Gastroenterology Division at the University of Michigan. Her practice even has one full-time PA whose job is dedicated to seeing hepatitis treatment patients. These visits are often very thorough and time-consuming. Treatment takes from six to 12 months, so it is important for you to learn how to best be reimbursed for a PA's time spent with chronic hepatitis C patients.

An assistant can directly oversee the patient's care as long as the patient is not new or undergoing a status change. Doctors can most often bill these services as "incident-to" a physician's service and get reimbursed 100 percent. The other option is to bill nurse services such as 99211 (Office or other outpatient visit), which carries with it only 80 percent reimbursement.

When counseling or coordination of care constitutes more than 50 percent of the encounter, time can be considered the controlling factor in determining the level of E/M services. It is important to document fully the counseling in the patient's medical records.

In follow-up appointments with hepatitis C patients, time can sometimes be the determinant factor in coding for E/M services. According to Pat Stout, CMC, CPC, an independent gastroenterology coding consultant in Knoxville, Tenn., each session can be different, depending on what problems must be addressed during that appointment.

If counseling does take up more than 50 percent of the session, you can bill based on time versus the key components. For example, use 99213 for a level-three visit for an established patient. The time component for this is 15 minutes. Therefore, if a PA spends 50 percent of a 15-minute office visit counseling a patient, then code 99213 may be used even if the criteria for the key components (history, examination and decision-making) are not met.

Be careful to comply with CPT guidelines concerning counseling. Education or counseling can encompass only seven activities:

Diagnostic results, impressions, and recommended diagnostic studies

Prognosis

Risks and benefits of treatment options

Instructions for management (treatment) and follow-up

Importance of compliance with chosen management (treatment) options

Risk factor reduction

Patient and family education.

Sometimes the time used counseling in these in-depth appointments cannot be covered solely by the criteria in the level-five E/M code. Code 99215 for a level-five visit encompasses only 40 minutes of time spent with the patient. Stout says that an appointment can take from 60 to 90 minutes in rare circumstances. In hepatitis C follow-up visits, use of a "prolonged service code is the exception, not the rule." However, it is necessary to be familiar with these codes in order to get the most out of any extra time spent counseling.

Prolonged service codes are divided into three categories: prolonged care with direct contact, care without direct contact, and physician standby services. Use the codes for direct patient contact (99354-99357) when time spent in direct E/M appointments exceeds level-five criteria. In most instances, codes +99354 (Prolonged physician service in the office or other outpatient setting requiring direct patient contact; first hour) and +99355 ( each additional 30 minutes) will be used. Codes 99358 and 99359 correspond to prolonged care given without direct contact. Physicians should note that it is not appropriate to report telephone calls (99371-99373) separately when reporting codes 99358 and 99359. Also, any communication beyond that rendered on a given date should use codes 99358-99359.

Always remember a few important facts:

Prolonged service codes are add-on codes and are reported separately, in addition to the appropriate E/M service code; never list them alone.

The total time spent providing services on a certain date is reported, even if the time is not continuous.

Prolonged services less than 30 minutes are reported with modifier -21 (Prolonged E/M services).

Ask your insurance carriers if they recognize prolonged service codes.

Interferon treatment for chronic hepatitis C patients has evolved over the years. Now, the preferred mode of treatment is pegylated interferon combined with ribavirin. This form of interferon is highly successful. Patients are given injections in the office or instructed on self-administration.

Several scenarios affect coding for interferon treatment. If an E/M service is performed along with the injection, you need to code for the level of service and for the injection administration. For example, use codes 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of three components) and 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections]; one vaccine [single or combination vaccine/toxoid]).

Add modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) onto the E/M code to show that two separate services were provided. Then, code for the actual supply of the drug using the 2002 HCPCS. An example is J9212 (Injection, interferon Alfacon-1, recombinant, 1 mcg). Always check the Medicare stipulations to view restrictions. 99212 must only be used for office or outpatient visits of an established patient at level two or higher.

There are some points to remember when filing for interferon treatment, according to Empire Medicare Services of New York:

1. A valid ICD-9-M diagnosis code must accompany each claim, such as 070.54 (Chronic hepatitis C without mention of hepatic coma).

2. Documentation must support medical necessity.

3. Dosing schedules must be consistent with the manufacturer's recommendations.

4. Self-administration by the patient can be denied by some insurance carriers.

Interferon is expensive, so you need to check with the carrier to determine levels of coverage. "Some insurers do not pay for the physician to supply the interferon. They will pay for the drug to be sent to the patient and for the doctor to administer it but not supply it," says Marylou Masters, billing representative with the University of North Texas Health Science Center.

Some patients administer Interferon themselves. In this case, gastroenterologists are responsible for educating the patients on proper administration of the drug. This service is often done by assistants and includes educating patients on injection procedures, side effects, and other pertinent information. Instruction takes the form of face-to-face dialogue, classes or videotapes. Masters says that their nurse practitioners educate the patients and usually spend about 60 to 90 minutes with each patient. "The level we can charge for injection training is usually a nurse visit unless she is assessing them." However, most of the exam is done during the initial consultation.

When a nurse is the caregiver, gastroenterologists can use 99211 (Established patient office or other outpatient visit). This is a level-one office visit only.