Gastroenterology Coding Alert

Question: When an asymptomatic patient comes to the office for his checkup prior to a screening colonoscopy, and the physician provides a level-two E/M service before sending the patient home, what diagnosis and CPT codes would we use? A co-worker told me to use 799.9, but I don't believe that's correct.

Ohio Subscriber
 
Answer: Code 799.9 (Other ill-defined and unknown causes of morbidity and mortality; other unknown and unspecified cause) implies that there is a symptom present, but the gastroenterologist cannot pinpoint it. So if the patient was truly asymptomatic, you should not use 799.9.

For a new patient, you should:

- report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and straightforward medical decision-making)

- attach ICD-9 code V72.83 (Special investigations and examinations; other specified preoperative examination) to 99202 to show that the patient was asymptomatic.
 
For an established patient, you should:

- report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; straightforward medical decision-making)

- attach ICD-9 code V72.83 to 99212 to show that the patient was asymptomatic.

Note: Medicare considers a preoperative visit for an asymptomatic patient included in the procedure code for screening colonoscopy. Therefore, Medicare will deny payment for the E/M service.