Gastroenterology Coding Alert

The need for proper documentation of evaluation and management (E/M) services was underscored recently in a memo from Nancy-Ann Min DeParle, the administrator of the Health Care Financing Administration (HCFA). The memo, dated June 1, states that Medicare audits for this year will focus on 99214 (established patient office or other outpatient visit) and 99233 (subsequent hospital care).

These codes accounted for a significant portion of the coding errors in the last two audits, DeParle announced. In fact, documentation for many of these services was only found to be sufficient to support services more appropriately described by CPT codes 99212 and 99231.

Although the memo should be taken seriously, gastroenterologists should not respond by systematically downcoding their E/M visits by one or two levels, according to Susan Calloway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. This memo is a warning to all physicians that they need to write good notes. This is a documentation issue.

Gastroenterologists need to write down everything that happened during the E/M encounter, she continues. Even if it turns out not to be important in the final analysis. No answers count, but if you dont write down the questions or the decision-making process that you went through, then you wont get paid.

Note: A complete copy of the memo is available at http://www.hcfa.gov/medicare/mip/cfolettr.htm.