Gastroenterology Coding Alert

Question: I think my gastroenterologists frequently perform established patient office visits that warrant coding at level four or higher, but I'm concerned about raising red flags for upcoding. Would you explain how I should determine when I'm justified in billing level four?

Tennessee Subscriber

Answer: Your first step in choosing the correct code is to look at the differences between the descriptors for 99213 and 99214:

• 99213 -- Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.

• 99214 -- ... a detailed history; a detailed examination; medical decision-making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family.

Important: You also need to be sure that the nature of the presenting problem and medical necessity support properly coding level four.

Experts warn: Some insurers put up red flags when a practice only reports 99213 for established patient E/M services. Payers wonder what type of patient care a practice is providing when it never codes anything higher or lower than that.