Gastroenterology Coding Alert

Learn multiple ways to report an asymptomatic screening, and you'll be ready no matter what the carrier wants

Gastroenterology offices that don't know how to properly report asymptomatic precolonoscopy screenings as both a preventive service and an evaluation and management service are at risk of filing ineffective claims and opening their offices up to payer suspicion.
 
Before scheduling a screening colonoscopy (G0105, G0121), a gastroenterologist evaluates a patient to make sure he has no conditions that would put him at risk during the procedure. If the patient has a risk factor that the gastroenterologist feels needs further exploration, he schedules an E/M service appointment before the colonoscopy.

Red flag: But what happens when the doctor performs the prescreening and the patient has no comorbidities? Should you report a preventive service or an E/M code?

There are two schools of thought on which code series to choose from when reporting asymptomatic precolonoscopy screenings: Some swear by preventive service codes, while others prefer to report an E/M service.

"This is a hot topic right now," says Linda Parks, MA, CPC, CMC, CCP, coding specialist at GI Diagnostics Endoscopy Center in Marietta, Ga. Parks says she has debated the issue with other experts at coding conferences and on gastroenterology-specific e-mail lists.

Unfortunately, professional debate has not led to a consensus on what the proper code is for reporting an asymptomatic patient's precolonoscopy screening.

Best bet: Contact each individual insurer before filing a claim to see what its policy is on coding asymptomatic precolonoscopy screenings. The insurer will likely tell you to file it as either a preventive service or an E/M service.

Here is a quick look at each reporting method, as well as some ways gastroenterology offices are avoiding the problem entirely -- while simultaneously making things easier on their doctors, nurses and fellow coders.

Method 1: Report a Preventive Service

Rochelle Cox, practice administrator at the Carolina Center for Liver Disease in Charlotte, reports preventive service codes for asymptomatic colonoscopy screenings.

"Depending on the patient's age, we code either 99386 (Initial comprehensive preventive medicine evaluation and management of an individual including an age- and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization[s], laboratory/diagnostic procedures, new patient; 40-64 years) or 99387 (... 65 years and over) for asymptomatic screenings," Cox says.

Explanation: The logic behind reporting the preventive codes is sound. Cox points out that CPT has no frequency-period guidelines for reporting preventive services, and there is no rule stating that only primary-care physicians can provide preventive services.

"As long as you perform a history and exam, which we do, you can report a preventive service," Cox says.

Method 2: Report a New Patient E/M Visit

However, other coding experts do not think an asymptomatic precolonoscopy screening qualifies as a preventive service. They prefer to report 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a problem-focused history, a problem-focused examination, and straightforward medical decision-making) with the diagnosis codes V72.83 (Other specified preoperative examination) and V76.51 (Special screening for malignant neoplasms; colon) attached to strengthen the claim. 

Explanation: Coders like Parks ascribe to the E/M service theory, contending that a precolonoscopy screening can never be rightfully called a preventive medicine visit.

"If you do submit a claim for a patient with no symptoms, you have to code it as a new patient or established patient visit," Parks says. "Preventive medicine codes for a new patient include an E/M component, age- and gender-appropriate history, ordering lab work, etc.

"I don't know of a gastroenterologist who is going to do all those things during a precolonoscopy screening," Parks says, "and you have to do all of these things in order to report a preventive medicine code."

Parks estimates that a typical precolonoscopy screening lasts 10 minutes, and no carriers will accept preventive codes for such a short service. She also disagrees with the idea that preventive codes can be reported more than once annually, despite the lack of a stated rule forbidding it.

"With preventive medicine codes, there is no set limit on how many of those you can report," Parks says. "But no insurance company is going to pay for more than one physical a year, and a preventive service is a physical."

Creative Option: Formulate a Checklist

Debate on preconoloscopy screening has led to some innovative ideas for dealing with asymptomatic patients, says Parks, who cites alternatives to single-patient visits that can save your office time, aggravation and money.

First step: Formulate a precolonoscopy screening checklist. The checklist should contain all factors that may put a patient at risk during a colonoscopy. Once you have created a checklist, you have several options for asymptomatic precolonoscopy screenings that do not involve single-patient office visits.

Use Phone, Group Screenings

Parks says one choice is to have a nurse call the patients individually and review the checklist with them to rule out any risk factors.

"If they have nothing to warrant an E/M visit, we just schedule the colonoscopy," Parks says. Faxing the checklist to the patient's primary-care physician and asking him to go over it with the patient is also a viable option, she adds.

Another method is conducting group precolonoscopy screenings, then scheduling E/M visits only for patients who require them.

Parks explains that group screenings involve a nurse practitioner (NP) or physician assistant (PA) conducting a session with 10 to 15 precolonoscopy screening patients. When the patient reports for the session, present him with your office's checklist and have him fill it out.

Then, have the NP or PA "explain the prep and procedure and go over the checklist with the entire group,"  Parks says. "If there's anything on the checklist that draws attention, then the patient is scheduled to see the physician before the colonoscopy."

Come to a Consensus Before Using Alternatives

Though Cox agrees that there are alternatives to traditional precolonoscopy screenings, she does not think anything can take the place of a face-to-face, one-on-one meeting with the gastroenterologist.

"These methods may work for some offices, but our practice doesn't feel comfortable having a PCP [perform the screening], because you're counting on someone else to do the work, but your office is assuming all the risk," she says.

If the PCP misses a comorbidity factor and it causes a complication during the colonoscopy, your office will have serious legal issues, she says. Cox's office finds performing the screening over the phone problematic, too.

"My doctor feels that he really needs to see the patient prior to the procedure, to establish a history and meet the patient," she says. Many gastroenterologists may not feel comfortable performing an invasive procedure like a colonoscopy on a person they've never met.

Best bet: Arrange a meeting between coders and gastroenterologists in your office to discuss the practicality of each of the alternative asymptomatic precolonoscopy screening options.

Decide whether each option is feasible for your office, then start work on a precolonoscopy screening checklist if the office decides to use one of the methods.