Gastroenterology Coding Alert

Learn the different criteria for CPT^®, MDM, and SDoH reporting.

As “Communication is Key for Better Documentation,” the previous article in this issue, shows, it can be difficult to pick out which documented details are necessary, which aren’t, and where the holes are. This comes up most often with procedures, E/M visits, and when deciphering social determinants of health (SDoH).

To help you out, we’ve compiled quiz questions to help get your mind moving in these three distinct documentation directions.

Question: If my provider performs an endoscopy procedure with ultrasound, what am I looking for in the documentation to help me select the best code?

Answer: Most GI procedure documentation should include the following information:

• Type of procedure
• Anatomic location of treatment or examination
• Procedure description
• Approach, such as transnasal, transoral, or percutaneous
• Devices or instruments used, such as forceps, snares, or balloons
• Findings

If, after reading the operative report, there is still a question about how far and what part(s) the physician examined, it is best to ask the gastroenterologist. Documentation about how far and what part(s) the physician examined is extremely important in helping you assign the appropriate codes, so you should discuss documentation requirements with providers to ensure maximum reimbursement along with correct coding.

Endoscopy with ultrasound (EUS): To accurately report endoscopy procedures with ultrasound, the documentation will need to include the extent and location of the scope visualization, as well as the regions examined during the ultrasound.

For example, if your gastroenterologist documents a transoral examination of the esophagus via esophagoscopy with endoscopic ultrasound, you can report the procedure with 43231 (Esophagoscopy, flexible, transoral; with endoscopic ultrasound examination).

However, let’s say the notes also describe examination of the esophagus, stomach, and he duodenum but the ultrasound was used to examine just the esophagus. These details will point you toward 43237 (… with endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures).

Coding alert: Also be on the lookout for whether the EUS included a biopsy. If so, look toward codes such as 43232 (… with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s)), 43242 (… with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis)), or 43238 (… with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), (includes endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures)).

Question: A new patient was recently referred to the gastroenterologist for esophageal pain following discharge from the emergency room. The documentation includes several pages of denied GI symptoms, and then a final determination that the pain appears to be coming from a neck injury rather than from a GI problem. The provider didn’t document time, and wants to report a higher-level evaluation and management (E/M) based on these notes, but I disagree. Who is correct?

Answer: It depends on what the notes say. Because the gastroenterologist didn’t indicate the amount of time spent during the encounter, your only choice is to report the visit based on the MDM.

MDM is a complex component of E/M coding. Just because encounter notes have a lot of information, doesn’t mean all the information can be used to determine MDM. As a coder, you need to level the encounter based on the number and complexity of problems addressed, the amount and/or complexity of data reviewed and analyzed, and the risk of complications and morbidity.

Based on the information given, it seems like there’s only evidence of the following:

• One self-limited or minor problem
• Minimal or no data to be reviewed and analyzed
• Minimal risk of morbidity from additional diagnostic testing or treatment

Therefore, you would likely report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/ or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter).

Question: We have a patient with diverticulosis and the provider wrote down that the patient is noncompliant with their diet regimen. Is this something I should report? How do I know when I should be reporting SDoH codes?

Answer: Clinicians should be documenting SDoH, and in general, you should be coding them. Presently, “more attention is being drawn to patients’ social determinants of health,” says Carol Pohlig, BSN, RN, CPC, manager of coding and education in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia. By accurately documenting SDoH, healthcare providers can better understand the factors affecting a patient’s health, leading to improved care management, resource allocation, and health outcomes.

When you notice potentially applicable social determinants of health in a patient’s medical record, ask yourself the following questions to determine whether their corresponding codes belong in the claim:

• Is the SDoH relevant to the patient’s health condition and been documented by the provider?
• Does the SDoH have a direct impact on the patient’s healthcare management, treatment plan, or outcomes?

If you can answer “yes” to these questions, you should include SDoH codes on the claim.

Your provider indicated a specific SDoH factor that ticks those boxes. “If a diverticulosis patient is noncompliant with a recommended dietary regimen, specifically a high fiber diet, it could lead to waste buildup and constipation which puts pressure on the diverticula, putting the patient at risk of more serious illness,” Laidy Martinez, CPC, CGIC, CASCC, profee coder at Children’s Health of Orange County in Orange County, California.

Keep in mind: The treating physician is not the only one who can document a patient’s SDoH. Per I.B.14, Z55-Z65 are some of the only codes in ICD-10-CM that you can report “based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider.” That’s because “this information represents social information, rather than medical diagnoses,” as the guidelines go on to elaborate.

So, you can use documentation “from social workers, community health workers, case managers, or nurses, if their documentation is included in the official medical record,” and “patient self-reported documentation … to assign codes for social determinants of health, as long as the patient self-reported information is signed-off by and incorporated into the medical record by either a clinician or provider,” per ICD-10-CM Official Guidelines.