Gastroenterology Coding Alert

Maximizing your evaluation and management service reimbursement for hepatitis patients is easier than you think. Follow four tips, and you'll learn how to make the most of your initial consult claims through diagnosis and follow-up.

Generally, the first service you will report for a potential hepatitis patient is a consult (for example, 99241-99245, Office consultation for a new or established patient ...), during which the gastroenterologist will take steps to confirm the diagnosis.

When it's properly documented, you will usually find that the consult is a high-level service. Typically, most first visits with a possible hepatitis patient involve a high level of decision-making. The doctor must evaluate risk factors, order lab tests and possibly provide counseling. Medical decision-making would fall into the moderate-complexity range for most patients. Most properly documented visits would probably fall into the 99243-99244 range.

"For our Alaskan practice, this is especially true as we usually get patients with little or no long-term care," says Joyce Carpenter, CPC, OGS, MCMC, billing lead at Internal Medicine Associates in Anchorage.

Example: The gastroenterologist sees a patient at the request of the patient's primary-care physician. The patient complains of severe fatigue and rapid weight loss and shows signs of jaundice.

After performing a comprehensive history and exam with moderate medical decision-making, the physician diagnoses acute hepatitis C without hepatic coma.

The gastroenterologist records his findings and provides a report back to the requesting physician.

For this visit, you should claim 99244 (... requires these three components: a comprehensive history; a comprehensive examination; and medical decision-making of moderate complexity) for the initial consultation.

Caution: Be sure you have met all the documentation requirements for a consult before billing the visit as such. If you cannot meet the requirements to report a consult, you will have to code a lower-paying outpatient E/M service (99201-99215, Office visit for the evaluation and management of a new or established patient...).

One often-requested lab test is 80074 (Acute hepatitis panel) for a hepatitis panel. The panel combines several tests, including the hepatitis B surface antigen (87340), hepatitis C antibody (86803), hepatitis B core IgM antibody (86705), and hepatitis A IgM antibody (86709).

The panel includes all the above individual tests. You should bill the panel code when your physician performs all the component codes, says Amy Hilderbrand, CPC, billing specialist for Gastrointestinal Specialists of Georgia in Austell.

When to order a panel: CMS gives two indications of when you may provide a hepatitis panel:

• To detect viral hepatitis infection when there are abnormal liver function test results, with or without signs or symptoms of hepatitis.

• Prior to and subsequent to liver transplantation.

Patients with a negative result may need a repeat panel when the time of exposure or stage of the disease is unknown, CMS regulations also state.

Important point: After the physician has established a hepatitis diagnosis, you may report only individual tests, as necessary, rather than the entire panel 80074. In other words, the physician should not repetitively order this test panel for a single patient when monitoring progress or changes after he has identified the initial specific cause of hepatitis.

After your physician has made a hepatitis diagnosis, you may be able to call on nonphysician practitioners (NPPs) to handle many follow-up tasks, including adjusting medications, ordering lab tests, and counseling and educating patients, says Quinten A. Buechner, MS, MDiv, ACS-FP/GI/PEDS, CPC, president of ProActive Consultants LLC in Cumberland, Wis.

Using NPPs in this way can free the gastroenterologist to see other patients -- and that can boost your office's bottom line.

Watch out: You must consider scope-of-practice rules prior to assigning services of this type to NPPs, Buechner says. Different states, facilities, etc., specify different rules for the services NPPs may render, and NPPs may not qualify to provide the above services in all states.

Example: Following scope-of-practice rules, the NPP provides a follow-up visit for a patient diagnosed with hepatitis C several weeks previously. The NPP takes a blood sample, examines the patient and provides a "current" history. The visit lasts about 20 minutes.

In this case, you can report the NPP's services using the appropriate E/M service code, for instance, 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...). Depending on the circumstances, you could report this service either "incident-to" the physician services or using the NPP's provider number. If you report the service as incident-to, be sure you meet all of the Medicare or other payer rules for such services.

Early in a hepatitis patient's treatment, the physician or NPP may spend a lot of time on counseling or teaching. In cases like these, you may be able to rely on time when determining an E/M service level, Buechner says.

If counseling and/or coordination of care make up more than half the time of the visit, you can forego history, exam and medical decision-making (MDM) and turn to time as the key component of the E/M, according to CPT guidelines.

Example: During a 20-minute visit, the NPP spends more than 15 minutes discussing treatment outcomes and possible problems of hepatitis. You may report 99213 (which has a reference time of 15 minutes) for this visit -- regardless of the documented levels of history, exam and MDM -- based on time alone.