Gastroenterology Coding Alert

Question: A patient presented to the office for his scheduled esophagoscopy with biopsy. Before the procedure, the patient recounted having severe, generalized stomach pain, and vomiting spells in the past week. The gastroenterologist performed the esophagoscopy, and then provided level-two evaluation and management service for the stomach pain and vomiting. I know that I should bill a level two E/M service, but what other codes should I report?

New Jersey Subscriber

Answer: Remember this: You can report a procedure code and the E/M service only if you prove that the gastroenterologist performed the esophagoscopy with biopsy, then lent separate time and expertise to the patient’s stomach pain and vomiting. To do this, you must provide rock-solid documentation on both procedures, and link the appropriate diagnosis codes to each service the gastroenterologist provides.

For the scenario given, you should:

• report 43202 (Esophagoscopy, flexible, transoral; with biopsy, single or multiple) for the esophagoscopy.
• attach ICD-10 code K20.9 (Esophagitis unspecified) to 43202 to represent the patient’s esophagitis.
• Bill 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straight forward medical decision making.) for the E/M service.
• link K30 (Functional dyspepsia) to 99212 to describe the patient’s stomach pain.
• attach R11.1- (Vomiting …) to 99212 to represent the patient’s vomiting.
• attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99212 to identify the service as separate from the esophagoscopy.

Hint: In this case, you can report both codes because the E/M (99212) service was a significant, separate service from the esophagoscopy (43202). However, if the gastroenterologist performed the esophagoscopy and then provided E/M service for stomach pain and vomiting related to the procedure, you would bundle the E/M into 43202.