Gastroenterology Coding Alert

Hint: Documentation discrepancy? Consult the gastroenterologist.

As your gastroenterology practice gains more knowledge about the newly enacted CPT^® codes and the updated E/M guidelines, don’t forget the importance of diagnosis coding. After all, it’s your ICD-10 codes that will confirm medical necessity of the procedures you perform, making them an essential tool in your reimbursement toolkit.

To get a firm handle on your GI practice’s ICD-10 coding prowess, check out three frequently asked questions, along with expert answers that will guide your code selection this year.

Don’t Hesitate to Contact Providers When Necessary

Suppose the physician’s dictation specifically states that the patient has a unilateral hernia, but then the documentation refers to treating a bilateral hernia, leaving the coder to wonder whether a unilateral or bilateral code applies. What should you do?

Solution: “Show the discrepancy in the documentation to the physician; once the answer is clarified, the physician should amend the chart note with the appropriate information,” says Elizabeth Cifers, MBA, MSW, CHC, CPC, of Elizabeth Cifers Consulting, LLC. “If the physician uses a scribe, educating both the physician and scribe is essential,” she adds.

If the chart documentation does not provide the highest level of specificity to assign a diagnosis code correctly, show the provider the options in the ICD-10-CM code book, so they can see the dilemma in selecting the correct code, she suggests. “Many physicians have been documenting the same way since residency and fellowship and do not realize the level of specificity that ICD-10-CM requires. Education concerning the problem is key to correcting and preventing future occurrences.”

Important: Don’t be afraid to speak up when there is a question or discrepancy in the documentation, Cifers advises. “Unless someone informs the physician, he or she may not know there is an issue.”

Understand How to Report Screening-Turned-Diagnostic Services

The physician’s colonoscopy documentation refers to a screening procedure, but later in the procedure notes, the doctor describes removing a malignant neoplasm from the colon. How can you report this service?

Solution: If your GI sees a patient for a screening colonoscopy, you should report Z12.11 (Encounter for screening for malignant neoplasm of colon) on the claim. However, keep in mind that if the physician initially intends to perform a screening service but ends up finding something such as a polyp that creates a diagnostic service, a second code will be required.

You need to be accurate on sequencing ICD-10 codes for a screening colonoscopy that ends up therapeutic, and would report the claim as follows:

• Report the screening ICD-10-CM code (Z12.11) listed first on the claim.
• Next, report the adenoma/polyp ICD-10-CM code based on the exact nature and site of polyp.

If, however, the GI is performing a diagnostic colonoscopy from the start, you’ll report a definitive diagnosis when your gastroenterologist has performed a procedure and the results confirm the condition.

Example: The gastroenterologist conducts a colonoscopy and confirms a diagnosis of Crohn’s disease with rectal bleeding. In this case, you should report K50.911 (Crohn’s disease, unspecified, with rectal bleeding) as the primary diagnosis for the colonoscopy.

However, if your gastroenterologist performs a procedure and the evidence is inconclusive, you should fall back on signs and symptoms. For instance, if, during the colonoscopy, the gastroenterologist finds results negative for Crohn’s disease, you should rely only on the signs and symptoms to establish medical necessity for services the doctor provides.

When seeking signs and symptoms to report, “remember first to locate the term in the Alphabetical Index, then use the Tabular list to verify the code selection, the laterality, and, if applicable, the seventh character code,” Cifers notes.

Avoid Suspected Diagnoses

Question: The physician performs an upper GI because they suspect that the patient is suffering from Barrett’s esophagus, but they ultimately find a gastric ulcer that they attribute to the patient’s long-term use of ibuprofen. They do not confirm Barrett’s esophagus. Which diagnosis code applies?

Answer: Physicians typically perform upper GI services to diagnose conditions after patients complain of symptoms. In some cases, the gastroenterologist will have a diagnosis in mind, but it’s important to never report suspected or rule-out diagnoses on claims. Instead, you’ll submit a claim using the final diagnosis (when applicable) or the signs and symptoms (when no diagnosis is confirmed).

Therefore, in this situation, you’ll report the primary diagnosis with K25.9 (Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation). In addition, you should add Z79.1 (Long-term [current] use of non-steroidal anti-inflammatories [NSAID]) as your secondary diagnosis.