Gastroenterology Coding Alert

Some gastroenterologists are now getting reimbursed for an E/M service prior to a screening colonoscopy by filing their claims with a preoperative examination diagnosis code. While some payers may be covering these claims, gastroenterologists should be aware that this is not a uniform practice, and many coding experts do not believe that the prescreening E/M is a reimbursable service.

Although many gastroenterologists perform a full evaluation of a patient before a screening colonoscopy (G0105, G0121) is scheduled, most physicians consider that E/M service preventive and therefore nonreimbursable. However, CMS issued Transmittal 1719 on preoperative services in August 2001, which many gastroenterologists are using to justify billing the prescreening E/M as a preoperative exam.

The memo instructs carriers that they should not automatically deny claims for preoperative clearance examinations. "Services identified with ICD-9 codes V72.81 (Preoperative cardiovascular examination) through V72.84 (Preoperative examination, unspecified) are not considered routine services and may not be denied, by carriers, as routine services," the memo states. "However, these ICD-9 codes do not, in and of themselves, establish medical necessity, therefore claims containing these codes may be subject to medical necessity determinations as described in [Medicare Carriers Manual section] 15047 H."

After reading the memo, Linda Parks, MA, CPC, lead coder at Atlanta Gastroen-terology Associates, decided to do a test by filing 20 claims for an E/M service prior to a screening colonoscopy with V72.83 (Other specified preoperative examination) as the primary diagnosis. Her test proved successful. "I waited a few weeks, and 19 of them were paid," Parks says. Medicare and various private payers paid the claims.

Parks uses V76.51 (Special screening for malignant neoplasms, colon) as the secondary diagnosis so the payer knows this is being done with a screening colonoscopy. In addition, the gastroenterologist dictates that this is a preoperative exam by noting in the file that the patient is cleared for surgery. Parks believes that this is in keeping with the instructions in the transmittal, which also revised the instructions for reporting preoperative exams. (Revisions are in italics.)

"All claims for preoperative medical examination and preoperative diagnostic tests (i.e., preoperative medical evaluations) must be accompanied by the appropriate ICD-9 code for preoperative examination (e.g., V72.81 through V72.84)," the transmittal states (this is also in MCM section 15047[G]). "Additional appropriate ICD-9 codes for the condition(s) that prompted surgery and for conditions that prompted the preoperative medical evaluation (if any), should also be documented on the claim. Other diagnoses and conditions affecting the patient may also be documented on the claim, if appropriate. The ICD-9 code that appears in the line item of a preoperative examination or diagnostic test must be the code for the appropriate preoperative examination (e.g., V72.81 through V72.84).

" Most of the prescreening E/M visits are billed as a level-two or -three service, Parks says. Also, patients are still presented with an advance beneficiary notice to sign, which indicates their financial responsibility for the visit in case their insurer does not cover it.

Before beginning to bill these E/M visits, however, gastroenterologists should understand that this is a controversial practice, and not everyone agrees that these services qualify as preoperative examinations. While acknowledging that there is a legitimate need for a prescreening E/M visit, Cecile Katzoff, MGA, associate vice president for consulting services, American Gastroenterological Association in Bethesda, Md., explains that it is simply not part of the national colorectal cancer screening benefit.

"The screening colonoscopy is a unique service that cannot be compared to mammograms, glaucoma screenings or other preventive benefits because it requires anesthesia," Katzoff says. When the colorectal cancer screening benefit was created, no mechanism was implemented to pay the gastroenterologist to see the patient ahead of time.

The problem with using a preoperative exam diagnosis in this situation, Katzoff says, is that preoperative exams are only medically necessary when the patient has an underlying condition such as diabetes, heart or respiratory disease that puts him or her at risk. Most gastroenterologists who require an evaluation prior to a screening see all patients, not just those with a previously identified underlying condition. In addition, the primary diagnosis in these situations should be the underlying condition. If the patient has diabetes, for example, the primary diagnosis code should reflect that condition, such as 250.70 (Diabetes with peripheral circulatory disorders).

Katzoff also argues that the preoperative exam is only separately reimbursable when the patient is sent to a physician who could manage the underlying condition, which is generally not going to be the gastroenterologist. "You can't refer a patient to yourself," she explains.

Others feel that Medicare's definition of a reimbursable preoperative service leaves room for those prescreening E/M visits where there is no previously identified underlying condition. Medicare defines reimbursable preoperative services in MCM section 15047(C) as those "E/M services performed that are not included in the global surgical package for the purpose of evaluating a patient's risk of perioperative complications and to optimize perioperative care."

Even when the patient has no underlying conditions, the face-to-face encounter with the gastroenterologist to explain the procedure and the patient's preparation for it may improve the patient's perioperative care by increasing compliance with the preparation instructions and thereby reducing the risk of an incomplete colonoscopy, according to Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the CPT advisory panel.

Weinstein also believes that a prescreening E/M is necessary with those patients who may not know of any previously identified underlying conditions because they scheduled an appointment directly with the gastroen-terologist. In those situations, the patient does not have a referral from a primary care physician who has already determined that the patient could tolerate the procedure.

In the end, this may be one of those coding issues with no uniform national policy, and the final reimbursement decision is left to the discretion of the carrier. "While the current statutes may say that visits prior to screening procedures are not covered because they are included in the procedure, carriers are not obligated to follow every statute to the letter," Weinstein says. "They are allowed to interpret."

Legislation recently introduced in the United States may eventually correct the situation. The Colon Cancer Screen for Life Act of 2002 (S.1931) sponsored by Democratic Sen. Joseph Lieberman of Connecticut would establish coverage for an outpatient office visit or consultation prior to a screening colonoscopy or with the beneficiary's decision to obtain such a screening, "regardless of whether such a screening is medically indicated with respect to the beneficiary." Reimbursement under the Medicare program is not available for these consultations, the bill notes, despite the fact that reimbursement is provided under such programs for similar consultations prior to a diagnostic colonoscopy.

The bill, which was introduced in the Senate on Feb. 11, has been referred to the Senate Finance Committee and would be effective July 1, 2002.

Parks bills the majority of her prescreening E/M visits as new patient office visits (99201-99205). Even though most of her practice's screening patients are referred by another physician, the visit is not billed as a consultation because the physician is referring the patient for a procedure and not requesting an opinion from the gastroen-terologist. Weinstein says, "In nearly all instances the visit prior to a screening colonoscopy is going to be a low-level E/M visit code, either a new patient or established patient visit (99211-99215). The visit is not really a consultation because there is no illness."

It is also important to distinguish between a prescreening E/M service and the standard history and physical that is performed on the day of the colonoscopy. "Our gastroenterologists do a complete evaluation of the patient a week prior to the colonoscopy," Parks explains. "They take a complete history, including the personal, family and social histories, then they do a physical exam of the patient. The medical decision-making is the decision that it's OK to do the procedure, that the patient is healthy enough for a colonoscopy."

Parks contrasts that with the standard history and physical that is not separately reimbursable. "In addition, we are also required to review the patients' histories with them prior to the procedure," she says. "In the ambulatory surgical center, a nurse takes the patient's history and the gastroenterologist reviews it with the patient before he or she is sedated, but we don't bill for that. It's included in the procedure, and it would be fraudulent if we tried to bill for that."

Note: CMS transmittal 1719 is available online at http://www.hcfa.gov/pubforms/transmit/r1719b3.pdf. Acrobat Reader is required to open the document. Download the software at no charge from http://codinginstitute.com.