Gastroenterology Coding Alert

Gastroenterology practices should avoid billing for a significant number of level-one established patient office visits (99211). Many times what is reported with code 99211 should be billed as a higher-level evaluation and management (E/M) service or not be billed at all.

Code 99211 should rarely be used by gastroenterologists, if at all, says Tammy Chidester, CPC, billing supervisor at Upshur Medical Management Services, a multi-specialty practice in Buckhannon, W.Va. Any type of medical decision-making, history or exam done by the gastroenterologist probably warrants a higher-level E/M code.

CPT defines 99211 as 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.

Missing from that definition are the history, examination and medical decision-making components that are required of most other E/M codes. Because the CPT states that the presence of a physician is not necessary, the code often is used to bill services by a non-physician provider, such as a registered nurse.

Injections Dont Always Qualify as E/M Service

One of the most common services reported with this code is the administration of an injection by a nurse or other non-physician provider. Although code 90782 (therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) also can be used to report injections, reimbursement is higher for 99211. The CPT seems to support the use of 99211 for injections when it cites an office visit for a 50-year-old female, established patient, with pernicious anemia for a weekly B12 injection as a clinical gastroenterological example of the code in its Appendix D.

Medicare disagrees. The Medicare Carriers Manual section 15502(D) states, CPT code 99211 cannot be used to report a visit solely for the purpose of receiving an injection which meets the definition of CPT codes 90782, 90783, 90784, or 90788.

If an additional medically necessary E/M service, such as a blood pressure check, also is performed at the time an injection is administered, Chidester believes that Medicare would then cover the service as an office visit. If just an injection is being given, however, she feels that gastroenterology practices should bill only the injection code.

Patient Education by Nurse Is Appropriate Use

Patient education by a nurse is another appropriate use for 99211, when there is documentation containing details regarding the services provided by the nurse in the patients medical record. For example, if a nurse teaches a patient with hepatitis how to self-inject interferon, Chidester feels this is an appropriate use of the code though she believes in practice it will be rare that only the nurse will see the patient. Usually that type of patient education is done in conjunction with a visit with the gastroenterologist and should be bundled into the gastroenterologists E/M service, she notes. You can only bill for the nurses visit if the patient does not see the gastroenterologist that day.

Many of the services such as telephone calls, the explanation of test results to the patient, and prescription refills for which gastroenterologists may try to bill code 99211 are probably not appropriate. The Medicare Carriers Manual section 5200.5 specifically states, Services rendered by a physician directly to a patient over the telephone are generally not covered.

Chidester also does not recommend the use of the code to report the explanation of test results to the patient. Youre probably going to have a hard time getting this by a payer if the nurse is talking with the patient, she explains. If the gastroenterologist speaks with the patient, then some form of medical decision-making is probably going on and a higher-level E/M code should be reported.

As for using the code to bill for refilling a patients prescription, I think Medicare would not like that, she says. What Medicare wants for code 99211 is probably what everyone else thinks is appropriate for code 99212. Medicare is looking for more than just the nurse doing a blood pressure check and then getting the gastroenterologist to sign off on it.

In some states, a legitimate use of this code by a gastroenterologist or nurse would be to bill the administration of a Helicobacter pylori (H. pylori) breath test. The CPT and Medicare have designated that codes 78267 (urea breath test, C-14; acquisition for analysis) and 83014 (Helicobacter pylori, breath test analysis; drug administration and sample collection) be used to report the administration of these tests. But the local medical review policies of several state Medicare carriers, such as Louisiana and Arkansas, still require the use of code 99211. (For more on H. pylori breath tests, see Ensure Proper Reimbursement for H. pylori Breath Tests on page 36 of the May 2000 Gastroenterology Coding Alert.)

Services of Nurse Are Billed Incident to

Services provided by a nurse that are covered by Medicare are billed incident to a physicians professional services. Medicare Carriers Manual section 2050.1(B) has stipulated that to bill as incident to, there must be direct supervision of the service by the gastroenterologist. Although direct personal supervision in the office does not mean that the gastroenterologist must be present in the room when the service is administered, it does mean that the gastroenterologist must be in the office suite and immediately available to provide assistance and direction if needed.

Traditionally, the gastroenterologist signs off on the patients medical record when an incident-to service has been performed. Although this is not a specific Medicare requirement, according to Chidester, It is the easiest way to prove that the gastroenterologist was present in the office at the time.

Finally, not all local payers reimburse for the E/M services provided by a nurse. Blue Cross Blue Shield of Alabama is one that doesnt, according to Carol Ethridge, CPC, a coding specialist at Baptist Health Centers, a practice management group for more than 75 medical practices in Birmingham, Ala. A March 1997 special bulletin issued by that Medicare carrier states, Although the Physicians Current Procedural Terminology (CPT) book specifies that office visit code 99211 may be used for visits that may not require the presence of a physician, a physician should not bill for an office visit if only the assistant or nurse actually sees the patient. This is true whether or not the physician is in the office at the time.

Because coding and reimbursement can vary from payer to payer, gastroenterologists should check with their local payers to get their specific policies regarding the use of code 99211.