Gastroenterology Coding Alert

Question: Our gastroenterologist spent 45 minutes in a discussion about a patients nutritional supplement, which the patient was receiving through a PEG tube. The gastroenterologist became involved when the floor nurse determined that the patient was not receiving enough nutrition. The nurse, a nutritionist and the primary care physician were also part of the discussion. What code should we use to report this service?

Ohio Subscriber

Answer: There is not a specific code for administering nutritional supplements, according to Pat Stout, CMT, CPC, an independent gastroenterology coding consultant and president of OneSource, a medical billing company in Knoxville, Tenn. Your question does not specify whether the gastroenterologist had face-to-face contact with the patient, but you might be able to bill an evaluation and management (E/M) service, depending on the nature of the gastroenterologists involvement and the other services provided.

To bill for an E/M service, the gastroenterologist must examine the patient directly, Stout says. If the discussion with the gastroenterologist took place over the telephone, no service can be billed. Often a primary care physician will call the gastroenterologist on the telephone and say, I have a patient on a nutritional supplement who is not thriving. What do you think? Although they may spend 45 minutes on the phone discussing the case, this is not a reimbursable service to the gastroenterologist because he or she did not see the patient, she explains.

If the primary care physician has requested the advice or opinion of the gastroenterologist, coders may bill an initial inpatient consultation (99251-99255) as long as the requirements for a consultation have been met. You can only bill for a consultation if the primary care physician specifically requests the gastroenterologists advice or opinion, explains Stout. That request should be noted in the patients shared medical record.

After the gastroenterologist has examined the patient at the request of the primary care physician, the gastroenterologist must report the findings back to the requesting physician, Stout says. For an inpatient consultation, the findings can be noted in the patients shared medical record.

If the primary care physician does not supply advice and/or an opinion and the encounter does not fulfill the requirements of a consultation, the gastroenterologist may report a subsequent hospital care service (99231-99233) as long as the key components for those codes are fulfilled.

The situation may change if the gastroenterologist performed the PEG tube placement. If the gastroenterologist, for example, did a nonendoscopic placement with the aid of fluoroscopy (43750) and the discussion takes place within the 10-day global period following the placement, no E/M service can be reported because it is considered part of the global package.

If the gastroenterologist performs an endoscopic PEG tube placement, (43246, which has a zero-day global period), then a subsequent hospital care code may be reported as long as the key components for those codes are fulfilled.

When determining the level of E/M service to report for an encounter, gastroenterologists usually look at the level of the three key components (history, examination and medical decision-making) performed during the encounter. Because your gastroenterologist spent 45 minutes doing what is in essence coordination of care, time could be considered the controlling factor for this E/M service instead of those three key components, says Stout.

For time to be a controlling factor, counseling and/or coordination of care must constitute 50 percent or more of the encounter, according to the CPT. If your gastroenterologist spent 15 minutes examining the patient and another 45 minutes in discussion with the other care-providers, coordination of care constituted 75 percent of this 60-minute encounter, and time may be used as the controlling factor. If the gastroenterologist spent 15 minutes examining the patient and 10 minutes in discussion with the other care-providers, then coordination of care constituted only 40 percent of the encounter and you would have to use the level of history, examination and medical decision-making to determine the level of visit.

When time is the controlling factor, the selection of an E/M code is based on the total duration of the encounter, not just the time spent coordinating care. If you have determined that the visit is an initial inpatient consultation, for example, the 60-minute encounter cited previously would be reported as 99253 (initial inpatient consultation for a new or established patient, which requires a detailed history and examination and medical decision-making of low complexity), which states, physicians typically spend 55 minutes at the bedside and on the patients hospital floor or unit.