Gastroenterology Coding Alert

Hint: Perform a quick audit of your claim to determine whether it's billable.

Gastroenterology practices perform colonoscopies often enough that they have may the codes committed to memory, but many coders are still hazy on the details of when it's okay to report an E/M visit the same day as a screening colonoscopy service. Since this is one of the most frequent questions submitted to Gastroenterology Coding Alert, it's clear that readers could use a quick primer, so read on for the facts.

First, Audit Your Visit

If your gastroenterologist frequently tacks an E/M code (99201-99215) on to her screening colonoscopy services, then chances are you haven't audited your claims in a while. Although this may sound like an unusual supposition, the reality is that any practice auditing its endoscopists' claims would immediately notice that the documentation is almost certainly lacking the elements required to report an E/M code.

For example, suppose your physician reported 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...) with nine out of his last ten screening colonoscopies (e.g., G0121, Colorectal cancer screening; colonoscopy on individual not meeting the criteria for high risk).

Ask this: When reviewing the documentation, ask yourself what the chief complaint is for the E/M visit. A patient presenting solely for the purpose of a screening colonoscopy would likely not have a chief complaint to report. In addition, ask yourself to locate the location, timing, quality, context, duration, severity, associated signs and symptoms and modifying factors of the patient's complaint. You are not likely to find any. Therefore, it's clear that the documentation does not meet the medical necessity for an E/M service.

Here's What Medicare Says

If your gastroenterologist persists in reporting E/M codes with screening colonos­copies, offer her the language from CMS or your local Medicare Administrative Contractor (MAC).

For example, Part B MAC Palmetto GBA updated its article on this topic on Aug. 7, 2017. In its directive, Palmetto notes, "The physician performing the colonoscopy may wish to see and evaluate the patient prior to the screening colonoscopy. In this case, the evaluation and management (E/M) visit is generally not separately billable."

Even in patients deemed high-risk, the reimbursement for the appropriate high-risk screening code (such as G0105, Colorectal cancer screening; colonoscopy on individual at high risk) already includes the pre-service work associated with a screening colonoscopy in a high-risk patient, Palmetto advises.

Here's When You CAN Report the E/M

Although you are typically out of luck when reporting an E/M for patients who present for screening colonoscopies, there are a few exceptions, according to the Medicare rules. You can report a separate E/M code when patients present for a screening colonoscopy and either of the following scenarios takes place, Palmetto says:

• You've documented all the required E/M components, and based on the evaluation, the physician decides not to perform the procedure
• You've documented all the required E/M components, and the gastro­enterologist determines that the patient's signs and symptoms warrant a diagnostic colonoscopy instead of the screening colonoscopy

In these situations, you will report the appropriate E/M code based on the elements documented. If your documentation meets the requirement in the second option above, you'll report the appropriate diagnostic colonoscopy code (such as 45378, Colonoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]), along with the E/M code.

In the event the E/M service is performed on the same day as the procedure, append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code since the Correct Coding Initiative bundles the E/M codes into the diagnostic colonoscopy codes or any same-day endoscopic procedure. Since GI endoscopic services are "zero day global" services, E/M services qualifying for reporting performed on a different date does not require a modifier, advises Glenn Littenberg MD, a gastroenterologist in Pasadena, Calif.

Resource: To read Palmetto's complete document on this topic, visit https://www.palmettogba.com/palmetto/providers.nsf/vMasterDID/8EELDY5430.

What About Conditions Requiring Special Consideration Before Colonoscopy?

Physicians commonly do screening or surveillance colonoscopies for patients with serious comorbid conditions, and perform medically necessary visits to provide for assessment (to determine whether the patient is stable enough to proceed) and for special instructions (such as how to manage anticoagulants, complex diabetic regimen, severe asthma, severe sleep apnea, etc.). In these situations, most Medicare contractors don't question E/M visits before a colonoscopy, Littenberg says.

In such cases, the ICD-10 coding should first list the medical condition that the gastroenterologist assesses and counsels. Payer policy differs regionally whether to use the screening or surveillance codes for the exam (such as Z10.11 for screening, Z86.010 for polyp history, etc.); or the code for a pre-op evaluation, such as Z01.810 (Encounter for preprocedural cardiovascular examination-e.g. history anticoagulation needing management) or Z01.818 (Encounter for other preprocedural examination), Littenberg says. If the reason relates to morbid obesity, codeany comorbidities such as sleep apnea, or at least the ICD-10 code for the patient's BMI.

"If there are no apparent requirements for use of such specific codes, chart documentation should make clear the medical necessity for the pre-procedure evaluation, even if the patient has no GI symptoms or disease," Littenberg says.

What About Non-Medicare Payers?

"Although not widely publicized, the Department of Labor published requirements for commercial plans that are compliant with Affordable Care Act regulations (meaning non-grandfathered employee sponsored plans, and thus means most commercial plans currently) must allow for a pre-screening colonoscopy visit, without deductible or copay, and also allow for colon prep materials and also allow for pathology without deductible or copay when screening becomes therapeutic," Littenberg says. "Some private plans may publish policy related to how to report these (E/M visit codes, versus preventive care visit codes), or restrict the level of service allowed."

Resource: For more on this topic, visit the Department of Labor's website at http://www.dol.gov/ebsa/faqs/faq-aca29.html.