Gastroenterology Coding Alert

Documentation errors or omissions plague even the best coder sooner or later. Take a peek at three typical areas you can improve upon, and watch some of those rejections disappear.

Before you decide to report 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal.

Typically, 5 minutes are spent performing or supervising these services), make sure that the encounter was medically necessary.

"Documentation should clearly indicate the supervising physician's involvement," said Bruce Rappoport, MD, CPC, CHCC, at The Coding Institute's Coding and Reimbursement Conference in Orlando, Fla.

For instance, 99211 is not appropriate for a "patient who's in and out the door for a blood pressure check. Something else has to be going on," Rappoport said.

Don't miss: Just as important as medical necessity, for billing purposes, a 99211 visit must have been ordered by the physician. Without an order from a physician, it would not be medically necessary if the patient walked into the office requesting a blood pressure check, adds Pat Larabee, CPC, CCP-P, a coding specialist with InterMed PA in South Portland, Maine.

Not so fast: If the physician told the patient to return at a particular interval for a blood pressure check then that  would qualify for a 99211 service, notes Michael Weinstein, MD, a gastroenterologist in Washington, D.C.,and former member of the AMA's CPT Advisory Panel. "The documentation should state that the reason for the patient's visit is based on physician's instructions," he says. The documentation should also include the findings of the visit, and mention that the physician has reviewed or will review the results of the visit.

Reasons for a 99211 visit might also include wound checks, suture removals, tube or catheter checks and repositioning, or hemorrhoid assessments.

What is the most commonly missed element in timebased coding? Time, says Rappoport. When coding is based on time, auditors will look at having time in your documentation. "The official recommendation is that the documentation should clearly indicate the total time," Rappoport adds.

Good advice: However time is documented, it needs to be in the medical record. Don't put all your eggs on a time stamp. While some electronic medical record programs include time stamps, without seeing how a system's time stamp works, it's hard to say if the "start" time indicates the time the physician entered the examination room or the time the patient came into the room. It's better for the physician to record that information, Rappoport recommends.

Example: Critical care code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) requires at least 30 minutes. If your documentation doesn't mention the amount of time spent providing critical care, an auditor will disallow use of this CPT code.

Rationale: Time needs to be there in the documentation because if the provider spent less than 30 minutes providing critical care, the definition for 99291 is not met and another E/M code would be needed, Rappoport stressed. Tally all the day's medically necessary critical care time. The Medicare Claims Processing Manual, Chapter 12, Section 30.6.12E, states that critical care codes 99291 and +99292 (...each additional 30 minutes [List separately in addition to code for primary service]) "are used to report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured patient." That's even if the time spent by your physician on that date is not continuous.

Critical care, by definition, requires a physician's presence. If you're doing audits, look at what took place above and below the critical care note. Your physician may have checked the boxes for critical care and time, but an auditor wants to know what was going on surrounding it.

Be Stingy With E/M-25

When using modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), the E/M service must be significant and separately identifiable from the same-day service or other procedure.

Example: An established patient with anemia reports to the office for a flexible sigmoidoscopy (45330, Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) The gastroenterologist checks with the patient about her digestive symptoms related to eating and discusses adjustments to her diet.

In this instance, the gastroenterologist provided an E/M service in addition to the sigmoidoscopy, so you append modifier 25 to the E/M code (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...)