Gastroenterology Coding Alert

Comparing your code utilization to that of other GI practices can be easier if you have national benchmarking data available to you. Fortunately, you can use information from CMS as your baseline when you create your comparisons.

Frank Cohen, director of analytics and business intelligence at Doctors Management, shared the averages for each specialty during his Jan. 16 presentation, “Risk-based Auditing: New Tools and Techniques.”

Check out the top five CPT^® codes reported by gastroenterology providers in 2019, based on CMS data.

Top-Billed Code: 99214

Gastroenterologists look toward 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components…) on 9.3 percent of all claims. In addition, when compared to all established outpatient E/M codes, GI physicians report 99214 about 46 percent of the time.

When considering 99214, make sure your physicians understand that medical necessity should be driving the code choice. Automated systems set up to document every possible piece of history and examination for every patient will certainly attract the attention of auditors if it leads you to check off more history and exam elements than necessary, prompting you to report a higher level code.

In addition, always remember that E/M codes aren’t completely diagnosis driven. Don’t assume you can report higher-level E/M codes for gastroenterology patients who appear to be “sicker” than others. Instead, you should always base your E/M choice on the documentation.

99213 Ranks Second

Coming in very close behind 99214 on the list last year was 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components…). GI physicians reported this code on 9.01 percent of Medicare claims. When compared to other outpatient established patient E/M codes, 99213 represented 45 percent of claims submitted to the Medicare program.

When choosing between 99213 and 99214, pay attention to the differences in the descriptors, which we’ve bolded:

• 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem-focused history, an expanded problem-focused examination, medical decision-making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient›s and/or family›s needs. Usually the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.)
• 99214 (…a detailed history, a detailed examination, medical decision-making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family.”

Remember that you need two out of three elements to report the service, unless you’re billing based on time. So, if your documentation reflects a detailed history, an expanded problem-focused examination, and low-complexity medical decision making, the right code is 99213 and not 99214, despite the detailed history.

Coming in Third is 43239

GI practices reported 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple) on seven percent of claims during 2019, according to CMS data.

Gastroenterologists often perform these EGDs to evaluate and diagnose issues occurring in the upper GI system. Keep in mind that endoscopy rules typically allow multiple billing of certain endoscopic procedures at the same session in a different site, if you append the appropriate modifier. Always check the National Correct Coding Initiative (NCCI) edits to ensure that you can separate the codes with a modifier.

99232 Ranks Fourth

Gastroenterologists billed 99232 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components…) on 6.68 percent of all claims last year. This subsequent hospital care code is on the Targeted Probe and Educate (TPE) active review lists for some of the Medicare Administrative Contractors (MACs), so you should be aware of the documentation requirements before reporting it.

What that means: TPE is a Medicare claims review process performed exclusively by the MACs. TPE targets at-risk providers and consists of three rounds of review, in which 20 to 40 claims per round are selected for an audit. The MACs decide how many claims a practice must furnish and when to send them.

When Part B MAC CGS Medicare, for instance, added subsequent hospital visits to its TPE reviews, the MAC listed the following findings as the reasons behind its audit probe:

• Lack of detailed history and medical decision making of high complexity
• Failed to submit the requested and required documentation.
• Billed the incorrect provider for the visit.
• Submitted split/shared visit without notes to back up significant face-to-face by provider

Always make sure your documentation is complete and thorough before reporting the subsequent hospital care codes to ensure you stay on the right side of the rules.

Colonoscopy Code 45380 Comes in Fifth

Present on 5.11 percent of CMS claims, code 45380 (Colonoscopy, flexible; with biopsy, single or multiple) describes a colonoscopy that includes biopsies, typically performed with cold disposable forceps.

Remember that even if you remove multiple polyps using cold biopsy forceps during the service, you should still only report one unit of this code. The reasoning? The descriptor clearly states, “single or multiple,” referring to the number of biopsies taken.